Provider Demographics
NPI:1467585828
Name:DECARDENAS, MIKE (MD)
Entity Type:Individual
Prefix:
First Name:MIKE
Middle Name:
Last Name:DECARDENAS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6230 SW 144TH ST
Mailing Address - Street 2:
Mailing Address - City:VILLAGE OF PALMETTO BAY
Mailing Address - State:FL
Mailing Address - Zip Code:33158-1827
Mailing Address - Country:US
Mailing Address - Phone:305-310-5451
Mailing Address - Fax:
Practice Address - Street 1:2525 SW 75TH AVE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33155-2800
Practice Address - Country:US
Practice Address - Phone:305-260-1852
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-14
Last Update Date:2008-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME44880174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL069854700Medicaid
FL50380OtherBCBS
FL96568OtherBLUE CROSS BLUE SHIELD
FL104014OtherAVMED
FL592461OtherNHP
FL50380OtherBCBS
FLI17403Medicare UPIN