=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003150053
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | IJACONSULTANTS PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/15/2012
-----------------------------------------------------
Last Update Date | 11/30/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6140 SW 70TH ST SECOND FLOOR
-----------------------------------------------------
City | SOUTH MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33143-3419
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-476-7933
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6140 SW 70TH ST SECOND FLOOR
-----------------------------------------------------
City | SOUTH MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33143-3419
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-476-7933
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | IRA JOEL AGATSTEIN
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 954-648-4148
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | ME44376
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------