Healthcare Provider Details

I. General information

NPI: 1215563861
Provider Name (Legal Business Name): ESPAILLAT MEDICAL GROUP PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/16/2020
Last Update Date: 03/16/2020
Certification Date: 03/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12002 SW 128TH CT STE 204
MIAMI FL
33186-4643
US

IV. Provider business mailing address

PO BOX 144295
CORAL GABLES FL
33114-4295
US

V. Phone/Fax

Practice location:
  • Phone: 305-234-8264
  • Fax:
Mailing address:
  • Phone: 305-234-8264
  • Fax: 305-255-1752

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. DIEGO ESPAILLAT PRESTOL
Title or Position: OWNER/ PRESIDENT
Credential: M.D.
Phone: 305-234-8264