Healthcare Provider Details

I. General information

NPI: 1730679317
Provider Name (Legal Business Name): KATHY MEJIA OD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/18/2018
Last Update Date: 08/13/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8004 NW 154TH ST # 366
MIAMI LAKES FL
33016
US

IV. Provider business mailing address

8004 NW 154TH ST # 366
MIAMI LAKES FL
33016-5814
US

V. Phone/Fax

Practice location:
  • Phone: 786-266-1105
  • Fax:
Mailing address:
  • Phone: 786-266-1105
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPC5526
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: