Healthcare Provider Details

I. General information

NPI: 1306717053
Provider Name (Legal Business Name): NICKLAUS CHILDREN'S PEDIATRIC SPECIALISTS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/16/2025
Last Update Date: 09/16/2025
Certification Date: 09/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3100 SW 62 AVENUE SUITE 105
MIAMI FL
33155
US

IV. Provider business mailing address

3100 SW 62ND AVE SUITE 105
MIAMI FL
33155-3009
US

V. Phone/Fax

Practice location:
  • Phone: 786-624-4121
  • Fax: 786-624-4196
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133VN1004X
TaxonomyPediatric Nutrition Registered Dietitian
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207SG0201X
TaxonomyClinical Genetics (M.D.) Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code2080P0206X
TaxonomyPediatric Gastroenterology Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code2080P0208X
TaxonomyPediatric Infectious Diseases Physician
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code2080P0210X
TaxonomyPediatric Nephrology Physician
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code2080P0216X
TaxonomyPediatric Rheumatology Physician
License Number
License Number State

VIII. Authorized Official

Name: MARCOS MESTRE
Title or Position: SVP
Credential: MD
Phone: 305-666-6511