Healthcare Provider Details

I. General information

NPI: 1306893011
Provider Name (Legal Business Name): BUENAVENTURA MEDICAL CENTER INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/28/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12305 SW 112TH ST
MIAMI FL
33186-4822
US

IV. Provider business mailing address

12305 SW 112TH ST
MIAMI FL
33186-4822
US

V. Phone/Fax

Practice location:
  • Phone: 305-274-7335
  • Fax: 305-274-7336
Mailing address:
  • Phone: 305-274-7335
  • Fax: 305-274-7336

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberHCC6910
License Number StateFL

VIII. Authorized Official

Name: MICHAEL MARTI
Title or Position: PRESIDENT
Credential:
Phone: 305-274-7335