Healthcare Provider Details

I. General information

NPI: 1477650695
Provider Name (Legal Business Name): GISELE VICTOR MARDY MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 12/20/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9299 SW 152TH ST #207
MIAMI FL
33157
US

IV. Provider business mailing address

9299W 152TH ST #207
MIAMI FL
33157
US

V. Phone/Fax

Practice location:
  • Phone: 305-253-6654
  • Fax: 305-235-3501
Mailing address:
  • Phone: 305-253-6654
  • Fax: 305-235-3501

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME0070216
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: