Healthcare Provider Details

I. General information

NPI: 1245578244
Provider Name (Legal Business Name): GUSTAVO A CARDENAS MD PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/25/2013
Last Update Date: 01/25/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11195 S JOG RD SUITE 6
BOYNTON BEACH FL
33437-1829
US

IV. Provider business mailing address

9142 DUPONT PL
WELLINGTON FL
33414-6476
US

V. Phone/Fax

Practice location:
  • Phone: 954-817-1445
  • Fax:
Mailing address:
  • Phone: 954-817-1445
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberME101884
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License NumberME101884
License Number StateFL

VIII. Authorized Official

Name: GUSTAVO A CARDENAS
Title or Position: PRESIDENT
Credential: M.D.
Phone: 954-817-1445