Basic Information
| Provider Information | |||||||||
| NPI: | 1609802438 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PERODIN | ||||||||
| FirstName: | YANICK | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11305 SW 128TH ST | ||||||||
| Address2: | |||||||||
| City: | MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331764481 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7864661718 | ||||||||
| FaxNumber: | 3056264854 | ||||||||
| Practice Location | |||||||||
| Address1: | 16555 NW 25TH AVE | ||||||||
| Address2: | NORTH DADE HEALTH CENTER | ||||||||
| City: | OPALOCKA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33054 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7864661718 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/23/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | ME0043125 | FL | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 68401500 | 05 | FL | MEDICAID |