Healthcare Provider Details

I. General information

NPI: 1245465863
Provider Name (Legal Business Name): JUAN CALISTO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/27/2009
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3200 SW 60TH CT STE 201
MIAMI FL
33155-4070
US

IV. Provider business mailing address

3200 SW 60TH CT SUITE #201
MIAMI FL
33155-4000
US

V. Phone/Fax

Practice location:
  • Phone: 305-662-8220
  • Fax: 305-665-2467
Mailing address:
  • Phone: 305-662-8320
  • Fax: 305-665-2467

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number27042
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code2086S0102X
TaxonomySurgical Critical Care Physician
License Number132498
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code2086S0120X
TaxonomyPediatric Surgery Physician
License Number132498
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: