Healthcare Provider Details

I. General information

NPI: 1619800539
Provider Name (Legal Business Name): SAMUEL JUSTIN HIDALGO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2026
Last Update Date: 06/08/2026
Certification Date: 06/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

711 E 9TH ST
HIALEAH FL
33010-4553
US

IV. Provider business mailing address

1181 BLUEBIRD AVE
MIAMI SPRINGS FL
33166-3115
US

V. Phone/Fax

Practice location:
  • Phone: 786-275-4054
  • Fax:
Mailing address:
  • Phone: 786-374-1680
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number13302
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: