Basic Information
Provider Information | |||||||||
NPI: | 1518133867 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | RECABARREN VELARDE | ||||||||
FirstName: | JUANA | ||||||||
MiddleName: | SOFIA | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 4780 SW 64TH AVE STE 103 | ||||||||
Address2: |   | ||||||||
City: | DAVIE | ||||||||
State: | FL | ||||||||
PostalCode: | 333144400 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9544341705 | ||||||||
FaxNumber: | 8006422398 | ||||||||
Practice Location | |||||||||
Address1: | 1604 TOWN CENTER BLVD | ||||||||
Address2: | SUITE 4C | ||||||||
City: | WESTON | ||||||||
State: | FL | ||||||||
PostalCode: | 33326 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9543841800 | ||||||||
FaxNumber: | 9543841802 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/07/2008 | ||||||||
LastUpdateDate: | 01/20/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 01/20/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | ME113380 | FL | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 007256000 | 05 | FL |   | MEDICAID | L3065 | 01 | FL | MEDICARE | OTHER |