Healthcare Provider Details

I. General information

NPI: 1083895536
Provider Name (Legal Business Name): CARLOS J MEZA-VALENCIA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/26/2007
Last Update Date: 03/27/2020
Certification Date: 03/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

936 SW 1ST AVE STE 838
MIAMI FL
33130-4520
US

IV. Provider business mailing address

936 SW 1ST AVE STE 838
MIAMI FL
33130-4520
US

V. Phone/Fax

Practice location:
  • Phone: 571-244-4684
  • Fax: 888-356-1032
Mailing address:
  • Phone: 571-244-4684
  • Fax: 888-356-1032

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: