Healthcare Provider Details

I. General information

NPI: 1659451227
Provider Name (Legal Business Name): NILZA KALLOS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/17/2006
Last Update Date: 12/08/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5555 PONCE DE LEON BLVD
MIAMI FL
33143-4721
US

IV. Provider business mailing address

5555 PONCE DE LEON BLVD
MIAMI FL
33143-4721
US

V. Phone/Fax

Practice location:
  • Phone: 305-689-0695
  • Fax:
Mailing address:
  • Phone: 305-689-0695
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number24066
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberME24066
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code2085U0001X
TaxonomyDiagnostic Ultrasound Physician
License Number24066
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: