Healthcare Provider Details

I. General information

NPI: 1568846780
Provider Name (Legal Business Name): AGDAMIS CARRAZANA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/17/2015
Last Update Date: 04/19/2024
Certification Date: 04/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2020 W 64TH ST
HIALEAH FL
33016-2607
US

IV. Provider business mailing address

2020 W 64TH ST
HIALEAH FL
33016-2607
US

V. Phone/Fax

Practice location:
  • Phone: 305-642-5366
  • Fax: 305-644-6407
Mailing address:
  • Phone: 305-642-5366
  • Fax: 305-644-6407

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number31600
License Number StatePR
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberME134437
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: