=====================================================
General NPI Number Information
=====================================================
NPI Number | 1285748285
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SOUTH DADE PRIMARY CARE, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/18/2006
-----------------------------------------------------
Last Update Date | 08/27/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9835 E HIBISCUS ST
-----------------------------------------------------
City | PALMETTO BAY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33157-5406
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-238-8561
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1000 NW 57TH CT STE 400
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33126-3292
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 786-485-1005
-----------------------------------------------------
Fax | 786-441-2156
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIEF EXECUTIVE OFFICER
-----------------------------------------------------
Name | MARK L MULLINIX
-----------------------------------------------------
Credential | AUTHORIZED OFFICIAL
-----------------------------------------------------
Telephone | 786-758-3135
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | ME0027176
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | ME0092409
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | ME0016658
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------