Healthcare Provider Details

I. General information

NPI: 1922200260
Provider Name (Legal Business Name): ADELA DINA MATTIAZZI MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/31/2007
Last Update Date: 12/12/2022
Certification Date: 12/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1611 NW 12TH AVE
MIAMI FL
33136-1005
US

IV. Provider business mailing address

12162 SW 143RD LN
MIAMI FL
33186-6081
US

V. Phone/Fax

Practice location:
  • Phone: 305-585-5215
  • Fax:
Mailing address:
  • Phone: 305-233-7932
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberME105012
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number9280
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License NumberME105012
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: