MEDICARE: MIA MOBIL DIAGNOSTIC INC

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	174400000X	Specialist	CRT63103	FL

General Provider Information

NPI Number	:	1972716181
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MIA MOBIL DIAGNOSTIC INC

Provider Business Mailing Address
First Line	:	28 MAJORCA AVE APT 4
Second Line	:
City	:	CORAL GABLES
State	:	FL
Zip	:	33134-4603
Country	:	US
Telephone Number	:	305-362-9522
Fax Number	:	305-362-9471

Provider Business Practice Location Address
First Line	:	9807 NW 80TH AVE UNIT 11F
Second Line	:
City	:	HIALEAH
State	:	FL
Zip	:	33016-2325
Country	:	US
Telephone Number	:	305-362-9522
Fax Number	:	305-362-9471

Authorized Official
Title or Position	:	PRESIDENT
Name	:	PROF. DANIEL R FUNDORA
Credential	:	CRT
Telephone Number	:	305-362-9522

Provider Enumeration Date	:	05/07/2007
Last Update Date	:	08/22/2020

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