Healthcare Provider Details

I. General information

NPI: 1659050276
Provider Name (Legal Business Name): MIKAELA DOMINIQUE CAMACHO MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/12/2023
Last Update Date: 07/12/2023
Certification Date: 07/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7031 SW 62ND AVE
SOUTH MIAMI FL
33143-4701
US

IV. Provider business mailing address

410 NW 9TH AVE
MIAMI FL
33128-1313
US

V. Phone/Fax

Practice location:
  • Phone: 305-284-7500
  • Fax:
Mailing address:
  • Phone: 786-794-2514
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License NumberTRN38652
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: