Basic Information
| Provider Information | |||||||||
| NPI: | 1891890059 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FRAGA PEDIATRICS & ASSOCIATES, P.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7765 NW 48TH ST STE 300 | ||||||||
| Address2: | |||||||||
| City: | DORAL | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331665404 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3054421740 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5590 W 20TH AVE STE 100 | ||||||||
| Address2: | |||||||||
| City: | HIALEAH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 330167061 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3058283997 | ||||||||
| FaxNumber: | 3058284696 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/13/2006 | ||||||||
| LastUpdateDate: | 12/26/2017 | ||||||||
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| AuthorizedOfficialLastName: | CASANOVA | ||||||||
| AuthorizedOfficialFirstName: | RENE | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3054421740 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080A0000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Adolescent Medicine | 208D00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 000711900 | 05 | FL | MEDICAID | 279232000 | 05 | FL | MEDICAID |