Healthcare Provider Details

I. General information

NPI: 1437045663
Provider Name (Legal Business Name): TUPAC MALLCU ESPINOZA SUAREZ SA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/16/2025
Last Update Date: 06/16/2025
Certification Date: 06/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15630 SW 80TH ST APT I-108
MIAMI FL
33193-3336
US

IV. Provider business mailing address

15630 SW 80TH ST APT I-108
MIAMI FL
33193-3336
US

V. Phone/Fax

Practice location:
  • Phone: 813-785-2741
  • Fax:
Mailing address:
  • Phone: 813-785-2741
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License Number25-288
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: