Provider Demographics
NPI:1114159118
Name:OPA-LOCKA PAIN MANAGEMENT, CORP
Entity Type:Organization
Organization Name:OPA-LOCKA PAIN MANAGEMENT, CORP
Other - Org Name:OPA MEDICAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:G
Authorized Official - Last Name:PADRON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:305-948-9958
Mailing Address - Street 1:1865 NE 163RD ST
Mailing Address - Street 2:
Mailing Address - City:NORTH MIAMI BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33162-4805
Mailing Address - Country:US
Mailing Address - Phone:305-948-9958
Mailing Address - Fax:305-948-9518
Practice Address - Street 1:1865 NE 163RD ST
Practice Address - Street 2:
Practice Address - City:NORTH MIAMI BEACH
Practice Address - State:FL
Practice Address - Zip Code:33162-4805
Practice Address - Country:US
Practice Address - Phone:305-948-9958
Practice Address - Fax:305-948-9518
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-10
Last Update Date:2010-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME050431174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL08587OtherMEDICARE ID-TYPE UNSPECIFIED
FLD15223Medicare UPIN