Healthcare Provider Details

I. General information

NPI: 1033704580
Provider Name (Legal Business Name): DANIEL CARLOS MIJARES
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/06/2021
Last Update Date: 10/24/2024
Certification Date: 10/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

437 N KROME AVE
HOMESTEAD FL
33030-6040
US

IV. Provider business mailing address

7700 SW 176TH ST
PALMETTO BAY FL
33157-6244
US

V. Phone/Fax

Practice location:
  • Phone: 786-378-8277
  • Fax: 305-328-4089
Mailing address:
  • Phone: 786-564-2670
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number9113118
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: