Healthcare Provider Details

I. General information

NPI: 1073924981
Provider Name (Legal Business Name): L. MARISCAL, M.D., PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/13/2014
Last Update Date: 01/14/2023
Certification Date: 12/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12991 SW 112TH ST
MIAMI FL
33186-4769
US

IV. Provider business mailing address

12991 SW 112TH ST
MIAMI FL
33186-4769
US

V. Phone/Fax

Practice location:
  • Phone: 786-298-3854
  • Fax:
Mailing address:
  • Phone: 786-703-8174
  • Fax: 786-703-8190

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME 95687
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: LIUSKA MARISCAL
Title or Position: OWNER
Credential: MD
Phone: 786-703-8174