Healthcare Provider Details

I. General information

NPI: 1295749281
Provider Name (Legal Business Name): DOUGLAS V HENAO RD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/28/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 NW 16TH ST #120 VAMC
MIAMI FL
33125-1624
US

IV. Provider business mailing address

1331 LINCOLN RD APT 1302
MIAMI BEACH FL
33139-2266
US

V. Phone/Fax

Practice location:
  • Phone: 305-575-3257
  • Fax:
Mailing address:
  • Phone: 305-484-0808
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: