Healthcare Provider Details

I. General information

NPI: 1790231728
Provider Name (Legal Business Name): SAN LAZARO MEDICAL GROUP, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/30/2016
Last Update Date: 01/29/2021
Certification Date: 01/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3271 NW 7TH ST STE 211
MIAMI FL
33125-4141
US

IV. Provider business mailing address

3271 NW 7TH ST STE 211
MIAMI FL
33125-4141
US

V. Phone/Fax

Practice location:
  • Phone: 786-294-0442
  • Fax: 786-294-0124
Mailing address:
  • Phone: 786-294-0442
  • Fax: 786-294-0124

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MS. NIDIA D DOMINGUEZ
Title or Position: VICE PRESIDENT
Credential: APRN
Phone: 786-294-0442