Healthcare Provider Details

I. General information

NPI: 1235828914
Provider Name (Legal Business Name): ORTHOMIAMI
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/08/2023
Last Update Date: 05/08/2024
Certification Date: 05/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3905 NW 107TH AVE STE 403
DORAL FL
33178-2785
US

IV. Provider business mailing address

7800 SW 87TH AVE SUITE A110
MIAMI FL
33173
US

V. Phone/Fax

Practice location:
  • Phone: 305-596-2828
  • Fax:
Mailing address:
  • Phone: 305-596-2828
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207XX0004X
TaxonomyOrthopaedic Foot and Ankle Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: NICOLE HOMMEN
Title or Position: BUSINESS MANAGER
Credential:
Phone: 305-596-2828