Basic Information
| Provider Information | |||||||||
| NPI: | 1942264643 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ESTACIO | ||||||||
| FirstName: | RICHMOND | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3601 W COMMERCIAL BLVD STE 5 | ||||||||
| Address2: | ANESCO NORTH BROWARD LLC | ||||||||
| City: | FORT LAUDERDALE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 333093392 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9544855666 | ||||||||
| FaxNumber: | 9544841651 | ||||||||
| Practice Location | |||||||||
| Address1: | 3601 W COMMERCIAL BLVD STE 5 | ||||||||
| Address2: | ANESCO NORTH BROWARD LLC | ||||||||
| City: | FORT LAUDERDALE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 333093392 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9544855666 | ||||||||
| FaxNumber: | 9544841651 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/12/2006 | ||||||||
| LastUpdateDate: | 09/20/2013 | ||||||||
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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 | 207L00000X | ME88044 | FL | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 269653300 | 05 | FL | MEDICAID |