Basic Information
| Provider Information | |||||||||
| NPI: | 1760129977 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PUPO BARROSO | ||||||||
| FirstName: | MIREILLE | ||||||||
| MiddleName: | DE LOS ANGELES | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3240 SW 81ST AVE | ||||||||
| Address2: | |||||||||
| City: | MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331553415 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7863405745 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 715 AVE PONCE DE LEON STOP 37.5 | ||||||||
| Address2: | |||||||||
| City: | HATO REY | ||||||||
| State: | PR | ||||||||
| PostalCode: | 009175032 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7877582000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/18/2022 | ||||||||
| LastUpdateDate: | 05/18/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/18/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | 16118-I | PR | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.