=====================================================
General NPI Number Information
=====================================================
NPI Number | 1659357358
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BELLAMAR MEDICAL OFFICE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/15/2005
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4811 NW 79TH AVE SUITE 2
-----------------------------------------------------
City | DORAL
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33166-5438
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-418-3855
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4811 NW 79TH AVE SUITE 2
-----------------------------------------------------
City | DORAL
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33166-5438
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | JOSE RIVERA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 305-418-3855
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | ME68564
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------