Provider Demographics
NPI:1407905193
Name:LLENSE, MIREYA (MD,)
Entity Type:Individual
Prefix:DR
First Name:MIREYA
Middle Name:
Last Name:LLENSE
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 1:7057 S.W. 22 ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33155-1624
Mailing Address - Country:US
Mailing Address - Phone:786-942-1667
Mailing Address - Fax:305-559-5333
Practice Address - Street 1:11865 SW 26TH ST
Practice Address - Street 2:SUITE G10
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33175-2400
Practice Address - Country:US
Practice Address - Phone:786-942-1667
Practice Address - Fax:305-559-5333
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME86749208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLE4996Medicare ID - Type Unspecified
FLH30901Medicare UPIN