Provider Demographics
NPI:1023037066
Name:IVAN ESPAILLAT MD PA
Entity Type:Organization
Organization Name:IVAN ESPAILLAT MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:
Authorized Official - First Name:IVAN
Authorized Official - Middle Name:
Authorized Official - Last Name:ESPAILLAT
Authorized Official - Suffix:
Authorized Official - Credentials:MD PA
Authorized Official - Phone:305-255-1127
Mailing Address - Street 1:PO BOX 440728
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33144-0728
Mailing Address - Country:US
Mailing Address - Phone:305-255-1127
Mailing Address - Fax:305-255-1669
Practice Address - Street 1:12002 SW 128TH CT
Practice Address - Street 2:SUITE 204
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33186-4639
Practice Address - Country:US
Practice Address - Phone:305-255-1127
Practice Address - Fax:305-255-1669
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-19
Last Update Date:2007-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME92158174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLQ0265Medicare ID - Type Unspecified