=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902175292
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DE LA PAZ MEDICAL AND WEIGHT LOSS PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/15/2011
-----------------------------------------------------
Last Update Date | 02/14/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12550 PINES BLVD
-----------------------------------------------------
City | PEMBROKE PINES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33027-1713
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 888-920-5599
-----------------------------------------------------
Fax | 888-921-9449
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 820897
-----------------------------------------------------
City | SOUTH FLORIDA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33082-0897
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 888-920-5599
-----------------------------------------------------
Fax | 888-921-9449
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. YIRA L DE LA PAZ
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 888-920-5599
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Clinic/Center
-----------------------------------------------------
License Number | ME89466
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------