=====================================================
General NPI Number Information
=====================================================
NPI Number | 1437404381
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | OB-GYN ASSOCIATES OF SOUTH FLORIDA LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/17/2012
-----------------------------------------------------
Last Update Date | 12/04/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3661 S MIAMI AVE STE 710
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33133-4214
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-860-5407
-----------------------------------------------------
Fax | 305-854-6521
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3661 S MIAMI AVE STE 710
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33133-4214
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-860-5407
-----------------------------------------------------
Fax | 305-854-6521
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | ALEXIS DOMINGUEZ
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 305-860-5407
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Clinic/Center
-----------------------------------------------------
License Number | ME 113513
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------