Basic Information
| Provider Information | |||||||||
| NPI: | 1194779959 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PETRICK | ||||||||
| FirstName: | MARIZA | ||||||||
| MiddleName: | SOUZA | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4960 SW 72ND AVE | ||||||||
| Address2: | SUITE 406 | ||||||||
| City: | MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331555544 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3056625200 | ||||||||
| FaxNumber: | 3052847948 | ||||||||
| Practice Location | |||||||||
| Address1: | 440 W 49TH ST | ||||||||
| Address2: | |||||||||
| City: | HIALEAH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 330123603 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3058285700 | ||||||||
| FaxNumber: | 3054615911 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/19/2006 | ||||||||
| LastUpdateDate: | 03/03/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | ME0054500 | FL | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | BP1721441 | 01 | FL | DEA | OTHER | ME0054500 | 01 | FL | MEDICAL LICENSE | OTHER |