Healthcare Provider Details

I. General information

NPI: 1184670333
Provider Name (Legal Business Name): ULISES D FERNANDEZ MIRO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/26/2006
Last Update Date: 06/08/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1874 SE PORT ST LUCIE BLVD
PORT ST LUCIE FL
34952-5545
US

IV. Provider business mailing address

1149 SAN MICHELE WAY
PALM BEACH GARDENS FL
33418-6704
US

V. Phone/Fax

Practice location:
  • Phone: 772-337-7676
  • Fax: 772-337-9034
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberME0076116
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: