Healthcare Provider Details

I. General information

NPI: 1346563855
Provider Name (Legal Business Name): CAMILO IVAN GARCIA GRACIA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/11/2010
Last Update Date: 09/13/2026
Certification Date: 09/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2801 NE 213TH ST STE 1211
AVENTURA FL
33180-1267
US

IV. Provider business mailing address

2801 NE 213TH ST STE 1211
AVENTURA FL
33180-1267
US

V. Phone/Fax

Practice location:
  • Phone: 954-213-7475
  • Fax:
Mailing address:
  • Phone: 954-213-7475
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084E0001X
TaxonomyEpilepsy Physician
License NumberMD489037
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code2084E0001X
TaxonomyEpilepsy Physician
License NumberME115714
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License NumberME115714
License Number StateFL
# 4
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License NumberMD489037
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: