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General NPI Number Information
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NPI Number | 1821404104
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Entity Type | Organization
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Legal Business Name | SAN MARCUS MEDICAL OFFICE, INC.
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Dates
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Enumeration Date | 07/07/2014
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Last Update Date | 07/07/2014
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Provider Practice Location Address
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Address Line | 5941 NW 173RD DR
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City | HIALEAH
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State | FL
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Zip | 33015-5109
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Country | US
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Telephone | 786-615-2713
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Fax | 786-615-3023
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Provider Business Mailing Address
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Address Line | 5941 NW 173RD DR
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City | HIALEAH
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State | FL
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Zip | 33015-5109
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Country | US
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Telephone | 786-615-2713
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Fax | 786-615-3023
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Authorized Official
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Title or Position | PRESIDENT/OWNER
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Name | IDALIA ACOSTA
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Credential | MD
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Telephone | 786-615-2713
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | ME66961
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License Number State | FL
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