=====================================================
General NPI Number Information
=====================================================
NPI Number | 1922180355
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MEDICAL DIAGNOSTIC ASSOC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/19/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 42 NW 27TH AVENUE SUITE 313
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33126
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-643-6858
-----------------------------------------------------
Fax | 305-643-9298
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 42 NW 27TH AVENUE SUITE 313
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33126
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-643-6858
-----------------------------------------------------
Fax | 305-643-9298
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MRS. CARIDAD LOPEZ
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 786-253-8370
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | ME49132
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------