Healthcare Provider Details

I. General information

NPI: 1194779959
Provider Name (Legal Business Name): MARIZA SOUZA PETRICK MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/19/2006
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

440 W 49TH ST
HIALEAH FL
33012-3603
US

IV. Provider business mailing address

4960 SW 72ND AVE SUITE 406
MIAMI FL
33155-5544
US

V. Phone/Fax

Practice location:
  • Phone: 305-828-5700
  • Fax: 305-461-5911
Mailing address:
  • Phone: 305-662-5200
  • Fax: 305-284-7948

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME0054500
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: