=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609832559
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SOUTH FLORIDA INFECTIOUS DISEASE AND TROPICAL MEDICINE CENTER LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/20/2006
-----------------------------------------------------
Last Update Date | 12/09/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5975 SUNSET DR STE 103
-----------------------------------------------------
City | SOUTH MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33143-5198
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-666-4044
-----------------------------------------------------
Fax | 305-667-8387
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5975 SUNSET DR STE 103
-----------------------------------------------------
City | SOUTH MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33143-5198
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-666-4044
-----------------------------------------------------
Fax | 305-666-8387
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VICE PRESIDENT
-----------------------------------------------------
Name | JORGE MEJIA
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 56-666-4044
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RI0200X
-----------------------------------------------------
Taxonomy Name | Infectious Disease Physician
-----------------------------------------------------
License Number | ME0059704
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------