=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053718106
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JDH MEDICAL GROUP, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/04/2014
-----------------------------------------------------
Last Update Date | 12/04/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12002 SW 128TH CT STE 210
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33186-4643
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-961-1671
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12002 SW 128TH CT STE 210
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33186-4643
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-961-1671
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. JOAQUIN HECHAVARRIA
-----------------------------------------------------
Credential | PHD, M.D. (F)
-----------------------------------------------------
Telephone | 305-961-1671
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------