Provider Demographics
NPI:1225113335
Name:FANDINO, ANGELA Z (MD)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:Z
Last Name:FANDINO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8175 NW 12TH ST
Mailing Address - Street 2:SUITE 306 (ATTN.: NYDIA AGUERO)
Mailing Address - City:DORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33126-1828
Mailing Address - Country:US
Mailing Address - Phone:786-845-0173
Mailing Address - Fax:305-470-5846
Practice Address - Street 1:8175 NW 12TH ST
Practice Address - Street 2:SUITE 306 (ATTN.: NYDIA AGUERO)
Practice Address - City:DORAL
Practice Address - State:FL
Practice Address - Zip Code:33126-1828
Practice Address - Country:US
Practice Address - Phone:786-845-0173
Practice Address - Fax:305-470-5846
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-26
Last Update Date:2011-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME14851208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL037673600Medicaid