Provider Demographics
NPI:1023568318
Name:PROHEALTH DORAL MEDICAL INC
Entity Type:Organization
Organization Name:PROHEALTH DORAL MEDICAL INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:OTTO
Authorized Official - Middle Name:
Authorized Official - Last Name:URDANETA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:786-422-4309
Mailing Address - Street 1:8247 NW 36TH ST
Mailing Address - Street 2:
Mailing Address - City:DORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33166-6613
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8247 NW 36TH ST
Practice Address - Street 2:
Practice Address - City:DORAL
Practice Address - State:FL
Practice Address - Zip Code:33166-6613
Practice Address - Country:US
Practice Address - Phone:786-422-4309
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-11
Last Update Date:2016-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME32388261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center