Healthcare Provider Details

I. General information

NPI: 1952667834
Provider Name (Legal Business Name): CARLOS ALBERTO LISTA-ENSENAT MD PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/05/2012
Last Update Date: 11/29/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12320 QUAIL ROOST DR
MIAMI FL
33177-4930
US

IV. Provider business mailing address

12320 QUAIL ROOST DR
MIAMI FL
33177-4930
US

V. Phone/Fax

Practice location:
  • Phone: 786-237-3070
  • Fax: 786-430-8198
Mailing address:
  • Phone: 786-237-3070
  • Fax: 786-430-8198

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberME109021
License Number StateFL

VIII. Authorized Official

Name: DR. CARLOS A LISTA-ENSENAT
Title or Position: OWNER
Credential: MD
Phone: 786-237-3070