Healthcare Provider Details

I. General information

NPI: 1790369379
Provider Name (Legal Business Name): AMED LEONARDO WONG HIERREZUELO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/10/2021
Last Update Date: 06/17/2026
Certification Date: 06/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2555 NW 102ND AVE STE 215
DORAL FL
33172-2131
US

IV. Provider business mailing address

131 SE 36TH AVE
HOMESTEAD FL
33033-5949
US

V. Phone/Fax

Practice location:
  • Phone: 305-226-0551
  • Fax:
Mailing address:
  • Phone: 786-626-4552
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-21-49707
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: