=====================================================
General NPI Number Information
=====================================================
NPI Number | 1316156854
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MIGUEL ANGEL GORDILLO D.P.M.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/22/2007
-----------------------------------------------------
Last Update Date | 03/25/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 613 E 49TH ST
-----------------------------------------------------
City | HIALEAH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33013-1963
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-828-2288
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5050 NW 7TH ST SUITE 203
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33126-3441
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-443-8301
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 213E00000X
-----------------------------------------------------
Taxonomy Name | Podiatrist
-----------------------------------------------------
License Number | PO2954
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------