Healthcare Provider Details

I. General information

NPI: 1801241658
Provider Name (Legal Business Name): ERIC RUNYON, D.O., P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

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

III. Provider practice location address

11760 SW 40TH ST SUITE 654
MIAMI FL
33175-3582
US

IV. Provider business mailing address

11760 SW 40TH ST SUITE 654
MIAMI FL
33175-3582
US

V. Phone/Fax

Practice location:
  • Phone: 786-615-6123
  • Fax: 786-615-6103
Mailing address:
  • Phone: 786-615-6123
  • Fax: 786-615-6103

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberOS8317
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberOS4300
License Number StateFL

VIII. Authorized Official

Name: MRS. CLAUDIA KNICKERBOKER
Title or Position: ADMINISTRATOR
Credential:
Phone: 786-615-6123