Healthcare Provider Details

I. General information

NPI: 1326444514
Provider Name (Legal Business Name): MIGUEL MARTIN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/14/2014
Last Update Date: 10/12/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6345 W 12TH AVE
HIALEAH FL
33012-6412
US

IV. Provider business mailing address

6345 W 12TH AVE
HIALEAH FL
33012-6412
US

V. Phone/Fax

Practice location:
  • Phone: 786-239-4764
  • Fax:
Mailing address:
  • Phone: 786-239-4764
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code176B00000X
TaxonomyMidwife
License NumberMW 301
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number15-205
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: