Healthcare Provider Details

I. General information

NPI: 1639559750
Provider Name (Legal Business Name): VIVIAN BILASANO MD LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/03/2015
Last Update Date: 01/29/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1951 SW 172ND AVE SUITE312
MIRAMAR FL
33029-5593
US

IV. Provider business mailing address

1951 SW 172ND AVE SUITE312
MIRAMAR FL
33029-5593
US

V. Phone/Fax

Practice location:
  • Phone: 954-320-7999
  • Fax: 954-320-7601
Mailing address:
  • Phone: 954-320-7999
  • Fax: 954-320-7601

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License NumberME 77619
License Number StateFL

VIII. Authorized Official

Name: DR. VIVIAN BILASANO
Title or Position: MANAGER
Credential: MD
Phone: 954-320-7999