Healthcare Provider Details

I. General information

NPI: 1760098099
Provider Name (Legal Business Name): DURBAN MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/22/2020
Last Update Date: 12/27/2020
Certification Date: 12/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1212 NW 79TH ST
MIAMI FL
33147-8209
US

IV. Provider business mailing address

1212 NW 79TH ST
MIAMI FL
33147-8209
US

V. Phone/Fax

Practice location:
  • Phone: 786-703-9896
  • Fax:
Mailing address:
  • Phone: 786-703-9896
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: OCTAVIO RODRIGUEZ
Title or Position: ADM
Credential:
Phone: 786-641-1312