Basic Information
| Provider Information | |||||||||
| NPI: | 1760990188 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DGM MSO, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 680 N UNIVERSITY DR | ||||||||
| Address2: | |||||||||
| City: | PEMBROKE PINES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 330246738 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9549812555 | ||||||||
| FaxNumber: | 9545386850 | ||||||||
| Practice Location | |||||||||
| Address1: | 4160 N ARMENIA AVE | ||||||||
| Address2: | |||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336076453 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8136738245 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/19/2018 | ||||||||
| LastUpdateDate: | 01/05/2022 | ||||||||
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| AuthorizedOfficialLastName: | HERNANDEZ | ||||||||
| AuthorizedOfficialFirstName: | MARLOW | ||||||||
| AuthorizedOfficialMiddleName: | B. | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 9545149360 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | DO | ||||||||
| NPICertificationDate: | 01/05/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 207Q00000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.