Healthcare Provider Details

I. General information

NPI: 1669935706
Provider Name (Legal Business Name): MARTIN MALDONADO-PUEBLA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/06/2019
Last Update Date: 02/05/2025
Certification Date: 02/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 NW 16TH ST
MIAMI FL
33125-1624
US

IV. Provider business mailing address

1201 NW 16TH ST
MIAMI FL
33125-1624
US

V. Phone/Fax

Practice location:
  • Phone: 305-575-7000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number155636
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code207RA0201X
TaxonomyAllergy & Immunology (Internal Medicine) Physician
License Number155636
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License NumberME155636
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: