Basic Information
| Provider Information | |||||||||
| NPI: | 1215981618 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DOCTOR'S MEDICAL CENTER, LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | DMC HEALTH MEDICAL CENTERS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 5605 NW 82ND AVE | ||||||||
| Address2: | |||||||||
| City: | DORAL | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331664000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3056855688 | ||||||||
| FaxNumber: | 7866185307 | ||||||||
| Practice Location | |||||||||
| Address1: | 1272 NW 119TH ST | ||||||||
| Address2: | |||||||||
| City: | MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331673232 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3056855688 | ||||||||
| FaxNumber: | 3056871817 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/20/2006 | ||||||||
| LastUpdateDate: | 04/02/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | DE PAZ | ||||||||
| AuthorizedOfficialFirstName: | VENTURA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT/ CEO | ||||||||
| AuthorizedOfficialTelephone: | 3056855688 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | PA | ||||||||
| NPICertificationDate: | 04/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 332900000X | N | Suppliers | Non-Pharmacy Dispensing Site | 207R00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 063667306 | 05 | FL | MEDICAID | 063667305 | 05 | FL | MEDICAID | 063667310 | 05 | FL | MEDICAID | 063667315 | 05 | FL | MEDICAID | 013915000 | 05 | FL | MEDICAID | 063667307 | 05 | FL | MEDICAID | 063667313 | 05 | FL | MEDICAID | 063667309 | 05 | FL | MEDICAID | 063667314 | 05 | FL | MEDICAID | 063667304 | 05 | FL | MEDICAID | 063667311 | 05 | FL | MEDICAID | 063667312 | 05 | FL | MEDICAID | 063667316 | 05 | FL | MEDICAID | 063667300 | 05 | FL | MEDICAID | 063667308 | 05 | FL | MEDICAID |