Healthcare Provider Details

I. General information

NPI: 1932657921
Provider Name (Legal Business Name): OAKS MEDICAL GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/19/2016
Last Update Date: 09/19/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7761 NW 146TH ST
MIAMI LAKES FL
33016-1559
US

IV. Provider business mailing address

7761 NW 146TH ST
MIAMI LAKES FL
33016-1559
US

V. Phone/Fax

Practice location:
  • Phone: 305-822-1243
  • Fax: 305-822-4260
Mailing address:
  • Phone: 305-822-1243
  • Fax: 305-822-4260

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA 9100128
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberME84810
License Number StateFL

VIII. Authorized Official

Name: ROBERTO CUCURULLO
Title or Position: MEMBER
Credential: PA
Phone: 305-822-1243