Healthcare Provider Details

I. General information

NPI: 1083202550
Provider Name (Legal Business Name): MIAMI LAKES PEDIATRICS PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/09/2021
Last Update Date: 01/09/2021
Certification Date: 01/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1199 W FLAGLER ST STE 10
MIAMI FL
33130-1055
US

IV. Provider business mailing address

14400 NW 77TH CT STE 102
MIAMI LAKES FL
33016-1590
US

V. Phone/Fax

Practice location:
  • Phone: 305-326-8887
  • Fax:
Mailing address:
  • Phone: 305-823-7768
  • Fax: 305-823-2211

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: CRISTINA ALFONSO
Title or Position: PRACTICE ADMINISTRATOR
Credential:
Phone: 305-823-7768