Healthcare Provider Details

I. General information

NPI: 1528133022
Provider Name (Legal Business Name): GARY D SMALL DPM CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/21/2006
Last Update Date: 10/20/2022
Certification Date: 10/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2645 SW 37 AVE #101
MIAMI FL
33133
US

IV. Provider business mailing address

2645 SW 37 AVE #101
MIAMI FL
33133
US

V. Phone/Fax

Practice location:
  • Phone: 305-444-7114
  • Fax: 305-444-9587
Mailing address:
  • Phone: 305-444-7114
  • Fax: 305-444-9587

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberPO2363
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number
License Number State

VIII. Authorized Official

Name: MISS SAMANTHA MARTINEZ
Title or Position: PRESIDENT
Credential:
Phone: 305-444-7114