Basic Information
| Provider Information | |||||||||
| NPI: | 1386045904 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NEW LASER EYE CENTER OF MIAMI, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1661 SW 37TH AVE | ||||||||
| Address2: | |||||||||
| City: | MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331451754 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3054612400 | ||||||||
| FaxNumber: | 3054612902 | ||||||||
| Practice Location | |||||||||
| Address1: | 1661 SW 37TH AVE | ||||||||
| Address2: | |||||||||
| City: | MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331451754 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3054612400 | ||||||||
| FaxNumber: | 3054612902 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/15/2014 | ||||||||
| LastUpdateDate: | 09/03/2015 | ||||||||
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| AuthorizedOfficialLastName: | LAZCANO | ||||||||
| AuthorizedOfficialFirstName: | GABRIEL | ||||||||
| AuthorizedOfficialMiddleName: | GEORGE | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER / PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3054612400 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207W00000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Ophthalmology |
ID Information
| ID | Type | State | Issuer | Description | 013442800 | 05 | FL | MEDICAID | 00A0D | 01 | FL | BCBS | OTHER |