Healthcare Provider Details

I. General information

NPI: 1053309617
Provider Name (Legal Business Name): ALICE BLAVO D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/07/2005
Last Update Date: 03/25/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5955 PONCE DE LEON BLVD
CORAL GABLES FL
33146-2423
US

IV. Provider business mailing address

5955 PONCE DE LEON BLVD
CORAL GABLES FL
33146-2423
US

V. Phone/Fax

Practice location:
  • Phone: 305-662-8668
  • Fax: 305-662-3723
Mailing address:
  • Phone: 305-662-8668
  • Fax: 305-662-3723

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberOS7055
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code2080P0202X
TaxonomyPediatric Cardiology Physician
License NumberOS7055
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: