Basic Information
| Provider Information | |||||||||
| NPI: | 1881630382 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VERDECIA | ||||||||
| FirstName: | LUIS | ||||||||
| MiddleName: | FELIPE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | SR. | ||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1240 NW 119TH ST | ||||||||
| Address2: | |||||||||
| City: | MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331673232 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3056855688 | ||||||||
| FaxNumber: | 3056887995 | ||||||||
| Practice Location | |||||||||
| Address1: | 1272 NW 119TH ST | ||||||||
| Address2: | |||||||||
| City: | MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331673232 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3056855688 | ||||||||
| FaxNumber: | 3056871817 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/22/2006 | ||||||||
| LastUpdateDate: | 12/01/2011 | ||||||||
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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 | 208D00000X | ME81400 | FL | Y | Allopathic & Osteopathic Physicians | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 260500700 | 05 | FL | MEDICAID |