Basic Information
| Provider Information | |||||||||
| NPI: | 1619124898 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DE LA MAZA | ||||||||
| FirstName: | ANTONIO | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8722 SW 212TH TER | ||||||||
| Address2: | |||||||||
| City: | CUTLER BAY | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331893879 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3052564509 | ||||||||
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| Practice Location | |||||||||
| Address1: | 10300 SW 216TH ST | ||||||||
| Address2: | |||||||||
| City: | CUTLER BAY | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331901003 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3052786434 | ||||||||
| FaxNumber: | 3052525881 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/19/2008 | ||||||||
| LastUpdateDate: | 09/30/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | ME# 0025026 | FL | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 001554300 | 05 | FL | MEDICAID | BCD & BS 2-29880 B | 01 | FL | AETNA F92800 | OTHER |