Healthcare Provider Details

I. General information

NPI: 1558657130
Provider Name (Legal Business Name): MANOR PLAZA PEDIATRIC & GENERAL MEDICINE INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/22/2011
Last Update Date: 03/06/2026
Certification Date: 03/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1234 NE 4TH AVE SUITE A
FORT LAUDERDALE FL
33304-1925
US

IV. Provider business mailing address

1234 NE 4TH AVE STE A
FORT LAUDERDALE FL
33304-1977
US

V. Phone/Fax

Practice location:
  • Phone: 954-779-1667
  • Fax: 954-760-7253
Mailing address:
  • Phone: 954-779-1667
  • Fax: 954-760-7253

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME0042195
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberME0042195
License Number StateFL

VIII. Authorized Official

Name: MRS. HELENA M GAVIRIA
Title or Position: MEDICAL DIRECTOR
Credential: M.D.
Phone: 954-779-1667