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General NPI Number Information
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NPI Number | 1174560619
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Entity Type | Organization
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Legal Business Name | ID PROFESSIONALS OF SOUTH FLORIDA LLC
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Dates
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Enumeration Date | 06/01/2006
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Last Update Date | 01/22/2009
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Provider Practice Location Address
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Address Line | 1790 W 49TH ST SUITE 400-9
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City | HIALEAH
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State | FL
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Zip | 33012-2992
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Country | US
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Telephone | 305-698-5997
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Fax | 305-698-5998
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Provider Business Mailing Address
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Address Line | PO BOX 371082
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City | MIAMI
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State | FL
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Zip | 33137-1082
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Country | US
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Telephone | 305-698-5997
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Fax | 305-698-5998
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. MARIO R. LOPEZ
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Credential | M.D.
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Telephone | 954-495-5102
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207RI0200X
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Taxonomy Name | Infectious Disease Physician
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License Number | ME75291
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License Number State | FL
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