Healthcare Provider Details

I. General information

NPI: 1649874868
Provider Name (Legal Business Name): ILEANA MUSTELIER POMARES MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/29/2020
Last Update Date: 09/06/2022
Certification Date: 09/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3805 W 20TH AVE STE 105
HIALEAH FL
33012-4532
US

IV. Provider business mailing address

6100 BLUE LAGOON DR STE 365
MIAMI FL
33126-7010
US

V. Phone/Fax

Practice location:
  • Phone: 305-557-2277
  • Fax: 786-621-7818
Mailing address:
  • Phone: 786-322-7333
  • Fax: 786-347-5022

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License NumberRN9264333
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number022102
License Number StatePR
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberACN1318
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: