Healthcare Provider Details

I. General information

NPI: 1285389288
Provider Name (Legal Business Name): NICKLAUS CHILDREN'S PEDIATRIC SPECIALISTS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/17/2022
Last Update Date: 04/09/2025
Certification Date: 04/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3100 SW 62ND AVE
MIAMI FL
33155-3009
US

IV. Provider business mailing address

PO BOX 947095
ATLANTA GA
30394-7095
US

V. Phone/Fax

Practice location:
  • Phone: 305-666-6511
  • Fax: 305-662-8291
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2084N0402X
TaxonomyNeurology with Special Qualifications in Child Neurology Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code2080P0008X
TaxonomyPediatric Neurodevelopmental Disabilities Physician
License Number
License Number State

VIII. Authorized Official

Name: MARCOS MESTRE
Title or Position: SVP
Credential:
Phone: 305-666-6511