Healthcare Provider Details

I. General information

NPI: 1710357769
Provider Name (Legal Business Name): DIANA LONDONO MD PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/02/2015
Last Update Date: 10/04/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

219 NW 12TH AVE SUITE C-5
MIAMI FL
33128-2205
US

IV. Provider business mailing address

219 NW 12TH AVE SUITE C-5
MIAMI FL
33128-2205
US

V. Phone/Fax

Practice location:
  • Phone: 305-548-4063
  • Fax:
Mailing address:
  • Phone: 305-548-4063
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License NumberME116814
License Number StateFL

VIII. Authorized Official

Name: DIANA CRISTINA LONDONO
Title or Position: PRESIDENT
Credential: MD
Phone: 310-948-6680