Healthcare Provider Details

I. General information

NPI: 1083468169
Provider Name (Legal Business Name): JOAN FERNANDEZ DE LA VEGA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/15/2024
Last Update Date: 08/14/2025
Certification Date: 08/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11510 QUAIL ROOST DR
MIAMI FL
33157-6548
US

IV. Provider business mailing address

11510 QUAIL ROOST DR
MIAMI FL
33157-6548
US

V. Phone/Fax

Practice location:
  • Phone: 305-256-3056
  • Fax:
Mailing address:
  • Phone: 305-256-3056
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberACN1742
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: