Provider Demographics
NPI:1093145831
Name:IVAN D CAMACHO MD PA
Entity Type:Organization
Organization Name:IVAN D CAMACHO MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:IVAN
Authorized Official - Middle Name:D
Authorized Official - Last Name:CAMACHO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:305-987-9375
Mailing Address - Street 1:79 SW 12 ST #3907
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33130-5215
Mailing Address - Country:US
Mailing Address - Phone:786-475-7555
Mailing Address - Fax:786-475-7556
Practice Address - Street 1:79 SW 12 ST #3907
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33130-5215
Practice Address - Country:US
Practice Address - Phone:786-475-7555
Practice Address - Fax:786-475-7556
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-14
Last Update Date:2013-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME109790207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty