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General NPI Number Information
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NPI Number | 1104817584
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Entity Type | Individual
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Provider Name | IVAN R ESPAILLAT MD
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Gender | Male
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Dates
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Enumeration Date | 11/03/2005
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Last Update Date | 12/08/2011
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Provider Practice Location Address
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Address Line | 12002 SW 128TH CT SUITE 204
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City | MIAMI
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State | FL
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Zip | 33186-4639
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Country | US
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Telephone | 305-234-8264
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Fax | 305-255-1752
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Provider Business Mailing Address
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Address Line | PO BOX 440728
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City | MIAMI
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State | FL
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Zip | 33144-0728
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Country | US
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Telephone | 305-234-8264
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Fax | 305-255-1752
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | ME92158
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License Number State | FL
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