Healthcare Provider Details

I. General information

NPI: 1376011551
Provider Name (Legal Business Name): PERSONALIZED MEDICINE INSTITUTE, LLC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/06/2018
Last Update Date: 09/15/2025
Certification Date: 09/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4765 SW 148TH AVE STE 404
DAVIE FL
33330-2128
US

IV. Provider business mailing address

4765 VOLUNTEER RD STE 404
DAVIE FL
33330-2128
US

V. Phone/Fax

Practice location:
  • Phone: 203-300-0147
  • Fax: 954-634-4293
Mailing address:
  • Phone: 954-374-7545
  • Fax: 954-374-7543

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State

VIII. Authorized Official

Name: MAXIMO JOSE FERNANDEZ
Title or Position: CEO
Credential: MD
Phone: 954-552-7209