Healthcare Provider Details

I. General information

NPI: 1669500328
Provider Name (Legal Business Name): VENETIAN ISLE MEDICAL OB GYN CONSULTANT INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/02/2007
Last Update Date: 06/02/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3001 W HALLANDALE BEACH BLVD SUITE 200
HALLANDALE FL
33009-5155
US

IV. Provider business mailing address

3001 WEST HALLANDALE BEACH BLVD SUITE 200
HALLANDALE FL
33009-5158
US

V. Phone/Fax

Practice location:
  • Phone: 954-456-4888
  • Fax: 954-456-9721
Mailing address:
  • Phone: 954-456-4888
  • Fax: 954-456-9721

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberME34571
License Number StateFL

VIII. Authorized Official

Name: DR. WAYNE P. DIGIACOMO
Title or Position: PRESIDENT
Credential: M.D.
Phone: 954-456-4888