Healthcare Provider Details

I. General information

NPI: 1356572689
Provider Name (Legal Business Name): TATIANA PERDOMO MIQUEL M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/04/2009
Last Update Date: 08/13/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3141 W MCNAB RD
POMPANO BEACH FL
33069-4806
US

IV. Provider business mailing address

5301 S CONGRESS AVE
ATLANTIS FL
33462-1149
US

V. Phone/Fax

Practice location:
  • Phone: 954-977-6977
  • Fax:
Mailing address:
  • Phone: 561-965-7300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License NumberME 113780
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: