Provider Demographics
NPI:1083078000
Name:MEDPLAN CLINIC, LLC
Entity Type:Organization
Organization Name:MEDPLAN CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:MANUEL
Authorized Official - Middle Name:
Authorized Official - Last Name:IGLESIAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:786-641-5348
Mailing Address - Street 1:8750 NW 36TH ST STE 300
Mailing Address - Street 2:
Mailing Address - City:DORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33178-2499
Mailing Address - Country:US
Mailing Address - Phone:786-641-5348
Mailing Address - Fax:305-615-1121
Practice Address - Street 1:150 NW 168TH ST STE 301
Practice Address - Street 2:
Practice Address - City:NORTH MIAMI BEACH
Practice Address - State:FL
Practice Address - Zip Code:33169-6051
Practice Address - Country:US
Practice Address - Phone:305-654-5440
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-06
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207R00000X
FL261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL018781000Medicaid