Healthcare Provider Details

I. General information

NPI: 1699710905
Provider Name (Legal Business Name): EDUARDO FANILLA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/19/2006
Last Update Date: 07/17/2024
Certification Date: 07/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6963 SW 117TH AVE
MIAMI FL
33183-2803
US

IV. Provider business mailing address

12301 SW 124TH CT
MIAMI FL
33186-5476
US

V. Phone/Fax

Practice location:
  • Phone: 786-595-3225
  • Fax: 786-595-7812
Mailing address:
  • Phone: 786-573-3152
  • Fax: 786-573-3152

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0204X
TaxonomyPediatric Emergency Medicine (Pediatrics) Physician
License NumberME82787
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: