Basic Information
| Provider Information | |||||||||
| NPI: | 1275731622 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MEIER DAVILA | ||||||||
| FirstName: | MIRKO | ||||||||
| MiddleName: | ALFREDO | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7857 N. UNIVERSITY DRIVE | ||||||||
| Address2: | |||||||||
| City: | PARKLAND | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33067 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9545187000 | ||||||||
| FaxNumber: | 9545187049 | ||||||||
| Practice Location | |||||||||
| Address1: | 7857 N. UNIVERSITY DRIVE | ||||||||
| Address2: | |||||||||
| City: | PARKLAND | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33067 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9545187000 | ||||||||
| FaxNumber: | 9545187049 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/06/2007 | ||||||||
| LastUpdateDate: | 10/08/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 51999 | MN | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | ME123357 | FL | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | ENROLLED | 05 | MN | MEDICAID |