Healthcare Provider Details

I. General information

NPI: 1477996544
Provider Name (Legal Business Name): MIVIP MEDICAL GROUP INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/09/2013
Last Update Date: 01/13/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

351 NW 42ND AVE SUITE 408
MIAMI FL
33126-5683
US

IV. Provider business mailing address

398 CAMINO GARDENS BLVD SUITE 102
BOCA RATON FL
33432-5827
US

V. Phone/Fax

Practice location:
  • Phone: 561-392-3341
  • Fax:
Mailing address:
  • Phone: 561-392-3341
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: ISAAC VERBUKH
Title or Position: OWBER
Credential: MD
Phone: 561-392-3341