Healthcare Provider Details

I. General information

NPI: 1306404843
Provider Name (Legal Business Name): GREGORY CARVAJAL PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/30/2019
Last Update Date: 05/30/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3425 NW 180TH ST
MIAMI GARDENS FL
33056-3429
US

IV. Provider business mailing address

3425 NW 180TH ST
MIAMI GARDENS FL
33056-3429
US

V. Phone/Fax

Practice location:
  • Phone: 786-663-3936
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License NumberPTA12304
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: