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General NPI Number Information
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NPI Number | 1972716181
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Entity Type | Organization
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Legal Business Name | MIA MOBIL DIAGNOSTIC INC
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Dates
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Enumeration Date | 05/07/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 9807 NW 80TH AVE UNIT 11F
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City | HIALEAH
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State | FL
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Zip | 33016-2325
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Country | US
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Telephone | 305-362-9522
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Fax | 305-362-9471
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Provider Business Mailing Address
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Address Line | 28 MAJORCA AVE APT 4
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City | CORAL GABLES
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State | FL
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Zip | 33134-4603
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Country | US
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Telephone | 305-362-9522
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Fax | 305-362-9471
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Authorized Official
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Title or Position | PRESIDENT
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Name | PROF. DANIEL R FUNDORA
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Credential | CRT
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Telephone | 305-362-9522
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | CRT63103
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License Number State | FL
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