Healthcare Provider Details

I. General information

NPI: 1316156854
Provider Name (Legal Business Name): MIGUEL ANGEL GORDILLO D.P.M.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/22/2007
Last Update Date: 03/25/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

613 E 49TH ST
HIALEAH FL
33013-1963
US

IV. Provider business mailing address

5050 NW 7TH ST SUITE 203
MIAMI FL
33126-3441
US

V. Phone/Fax

Practice location:
  • Phone: 305-828-2288
  • Fax:
Mailing address:
  • Phone: 305-443-8301
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License NumberPO2954
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: