Healthcare Provider Details

I. General information

NPI: 1871816637
Provider Name (Legal Business Name): MARIOLA VIVIANA IDROBO CORDERO M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/09/2010
Last Update Date: 06/12/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3100 SW 62ND AVE
MIAMI FL
33155
US

IV. Provider business mailing address

3100 SW 62ND AVE
MIAMI FL
33155-3009
US

V. Phone/Fax

Practice location:
  • Phone: 305-666-6511
  • Fax:
Mailing address:
  • Phone: 305-666-6511
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME106445
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code207PP0204X
TaxonomyPediatric Emergency Medicine (Emergency Medicine) Physician
License NumberME106445
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: