Provider Demographics
NPI:1083202550
Name:MIAMI LAKES PEDIATRICS PLLC
Entity Type:Organization
Organization Name:MIAMI LAKES PEDIATRICS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:CRISTINA
Authorized Official - Middle Name:
Authorized Official - Last Name:ALFONSO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-823-7768
Mailing Address - Street 1:14400 NW 77TH CT STE 102
Mailing Address - Street 2:
Mailing Address - City:MIAMI LAKES
Mailing Address - State:FL
Mailing Address - Zip Code:33016-1590
Mailing Address - Country:US
Mailing Address - Phone:305-823-7768
Mailing Address - Fax:305-823-2211
Practice Address - Street 1:1199 W FLAGLER ST STE 10
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33130-1055
Practice Address - Country:US
Practice Address - Phone:305-326-8887
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MIAMI LAKES PEDIATRICS PLLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-01-09
Last Update Date:2021-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL103180601Medicaid