MEDICARE: GREGORY CARVAJAL PTA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2081S0010X	Sports Medicine (Physical Medicine & Rehabilitation) Physician	PTA12304	FL

General Provider Information

NPI Number	:	1306404843
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GREGORY CARVAJAL PTA

Provider Business Mailing Address
First Line	:	3425 NW 180TH ST
Second Line	:
City	:	MIAMI GARDENS
State	:	FL
Zip	:	33056-3429
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3425 NW 180TH ST
Second Line	:
City	:	MIAMI GARDENS
State	:	FL
Zip	:	33056-3429
Country	:	US
Telephone Number	:	786-663-3936
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/30/2019
Last Update Date	:	05/30/2019

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Directions to “ GREGORY CARVAJAL PTA” Practice Location

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