MEDICARE: DARVIS EDUARDO DAGER LISSABET MD

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	208D00000X	General Practice Physician	16810	PR
2	390200000X	Student in an Organized Health Care Education/Training Program
3	208D00000X	General Practice Physician	1654	FL

General Provider Information

NPI Number	:	1720765506
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DARVIS EDUARDO DAGER LISSABET MD

Provider Business Mailing Address
First Line	:	9121 W SUNRISE BLVD
Second Line	:
City	:	PLANTATION
State	:	FL
Zip	:	33322-5273
Country	:	US
Telephone Number	:	954-624-5155
Fax Number	:

Provider Business Practice Location Address
First Line	:	2621 CLEVELAND AVE
Second Line	:
City	:	FORT MYERS
State	:	FL
Zip	:	33901-5802
Country	:	US
Telephone Number	:	787-658-0200
Fax Number	:	787-658-0640

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

Provider Enumeration Date	:	07/03/2023
Last Update Date	:	08/26/2024

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