Healthcare Provider Details

I. General information

NPI: 1760129977
Provider Name (Legal Business Name): MIREILLE DE LOS ANGELES PUPO BARROSO MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/18/2022
Last Update Date: 05/19/2025
Certification Date: 05/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1272 NW 119TH ST
MIAMI FL
33167-3232
US

IV. Provider business mailing address

1272 NW 119TH ST
MIAMI FL
33167-3232
US

V. Phone/Fax

Practice location:
  • Phone: 305-685-5688
  • Fax:
Mailing address:
  • Phone: 305-685-5688
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number16118-I
License Number StatePR
# 2
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberACN1532
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: