Healthcare Provider Details

I. General information

NPI: 1376548560
Provider Name (Legal Business Name): EDWARD M FIDALGO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2005
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3659 S MIAMI AVE STE 5005
MIAMI FL
33133-4221
US

IV. Provider business mailing address

3659 S MIAMI AVE STE 5005
MIAMI FL
33133-4221
US

V. Phone/Fax

Practice location:
  • Phone: 305-854-2899
  • Fax: 305-859-9677
Mailing address:
  • Phone: 305-854-2899
  • Fax: 305-859-9677

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberME65256
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: