Healthcare Provider Details

I. General information

NPI: 1396308573
Provider Name (Legal Business Name): CARLOS ALFREDO MIJARES
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/15/2019
Last Update Date: 04/15/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3402 DAVIE RD APT 215
DAVIE FL
33314-1623
US

IV. Provider business mailing address

3402 DAVIE RD APT 215
DAVIE FL
33314-1623
US

V. Phone/Fax

Practice location:
  • Phone: 786-316-2308
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: