MEDICARE: IVAN D CAMACHO MD PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207N00000X	Dermatology Physician	ME109790	FL

General Provider Information

NPI Number	:	1093145831
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	IVAN D CAMACHO MD PA

Provider Business Mailing Address
First Line	:	79 SW 12 ST #3907
Second Line	:
City	:	MIAMI
State	:	FL
Zip	:	33130-5215
Country	:	US
Telephone Number	:	786-475-7555
Fax Number	:	786-475-7556

Provider Business Practice Location Address
First Line	:	79 SW 12 ST #3907
Second Line	:
City	:	MIAMI
State	:	FL
Zip	:	33130-5215
Country	:	US
Telephone Number	:	786-475-7555
Fax Number	:	786-475-7556

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. IVAN D CAMACHO
Credential	:	M.D.
Telephone Number	:	305-987-9375

Provider Enumeration Date	:	11/14/2013
Last Update Date	:	11/14/2013

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