Healthcare Provider Details

I. General information

NPI: 1902174758
Provider Name (Legal Business Name): GARY D. SMALL DPM CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/08/2011
Last Update Date: 05/12/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2645 SW 37TH AVE SUITE 704
MIAMI FL
33133-2754
US

IV. Provider business mailing address

2645 SW 37TH AVE SUITE 704
MIAMI FL
33133-2754
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 TaxonomyY
Taxonomy Code332900000X
TaxonomyNon-Pharmacy Dispensing Site
License Number
License Number State

VIII. Authorized Official

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