Provider Demographics
NPI:1033492723
Name:CLARA BACCINI, MD, PA
Entity Type:Organization
Organization Name:CLARA BACCINI, MD, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CLARA
Authorized Official - Middle Name:
Authorized Official - Last Name:BACCINI JAUREGUI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-570-2225
Mailing Address - Street 1:13290 KEYSTONE TER
Mailing Address - Street 2:
Mailing Address - City:NORTH MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33181-2254
Mailing Address - Country:US
Mailing Address - Phone:305-570-2225
Mailing Address - Fax:305-899-0411
Practice Address - Street 1:4791 W 4TH AVE
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33012-3938
Practice Address - Country:US
Practice Address - Phone:305-570-2225
Practice Address - Fax:305-899-0411
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-20
Last Update Date:2022-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME107797207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL022-462-200Medicaid