Healthcare Provider Details

I. General information

NPI: 1548776503
Provider Name (Legal Business Name): MIAMI SHORES PEDIATRICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/28/2017
Last Update Date: 12/28/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9715 NE 2ND AVE
MIAMI SHORES FL
33138-2310
US

IV. Provider business mailing address

9715 NE 2ND AVE
MIAMI SHORES FL
33138-2310
US

V. Phone/Fax

Practice location:
  • Phone: 305-757-8040
  • Fax:
Mailing address:
  • Phone: 305-757-8040
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME82129
License Number StateFL

VIII. Authorized Official

Name: LAURA ISIS FERNANDEZ-ORTIZ
Title or Position: PRESIDENT
Credential: MD
Phone: 305-757-8040