Healthcare Provider Details

I. General information

NPI: 1962098434
Provider Name (Legal Business Name): PODOCARE CLINICAL SPECIALIST PROFESSIONAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/17/2020
Last Update Date: 12/17/2020
Certification Date: 12/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2000 NW 87TH AVE STE 217
DORAL FL
33172-2657
US

IV. Provider business mailing address

2000 NW 87TH AVE STE 217
DORAL FL
33172-2657
US

V. Phone/Fax

Practice location:
  • Phone: 305-396-8731
  • Fax: 305-396-8732
Mailing address:
  • Phone: 305-396-8731
  • Fax: 305-396-8732

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: GREGORIO CABAN
Title or Position: PRESIDENT ADMIN
Credential: DPM
Phone: 305-396-8731