Healthcare Provider Details

I. General information

NPI: 1033725007
Provider Name (Legal Business Name): FABIANO NASSAR DE CASTRO CARDOSO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/16/2020
Last Update Date: 01/06/2025
Certification Date: 01/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1611 NW 12TH AVE FL 33136
MIAMI FL
33136-1005
US

IV. Provider business mailing address

1611 NW 12TH AVE FL 33136
MIAMI FL
33136-1005
US

V. Phone/Fax

Practice location:
  • Phone: 305-585-8178
  • Fax:
Mailing address:
  • Phone: 305-585-8178
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberME170295
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: