Healthcare Provider Details

I. General information

NPI: 1891529715
Provider Name (Legal Business Name): SOUTH FLORIDA PEDIATRIC UROLOGY LLP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/02/2024
Last Update Date: 09/02/2024
Certification Date: 09/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3200 SW 60TH CT STE 104
MIAMI FL
33155-4069
US

IV. Provider business mailing address

3200 SW 60TH CT STE 104
MIAMI FL
33155-4069
US

V. Phone/Fax

Practice location:
  • Phone: 305-669-6448
  • Fax:
Mailing address:
  • Phone: 305-669-6448
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2088P0231X
TaxonomyPediatric Urology Physician
License Number
License Number State

VIII. Authorized Official

Name: MRS. DESIREE N MOURE
Title or Position: PRACTICE ADMINISTRATOR
Credential:
Phone: 305-669-6448