Healthcare Provider Details

I. General information

NPI: 1720077308
Provider Name (Legal Business Name): GUILLERMO JUAN LLOSA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 10/17/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11400 N KENDALL DR SUITE A211
MIAMI FL
33176-1029
US

IV. Provider business mailing address

11400 N KENDALL DR SUITE A211
MIAMI FL
33176-1029
US

V. Phone/Fax

Practice location:
  • Phone: 305-274-2255
  • Fax: 305-274-2211
Mailing address:
  • Phone: 305-274-2255
  • Fax: 305-274-2211

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License NumberME0038885
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: