Provider Demographics
NPI:1548776503
Name:MIAMI SHORES PEDIATRICS
Entity Type:Organization
Organization Name:MIAMI SHORES PEDIATRICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:ISIS
Authorized Official - Last Name:FERNANDEZ-ORTIZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:305-757-8040
Mailing Address - Street 1:9715 NE 2ND AVE
Mailing Address - Street 2:
Mailing Address - City:MIAMI SHORES
Mailing Address - State:FL
Mailing Address - Zip Code:33138-2310
Mailing Address - Country:US
Mailing Address - Phone:305-757-8040
Mailing Address - Fax:
Practice Address - Street 1:9715 NE 2ND AVE
Practice Address - Street 2:
Practice Address - City:MIAMI SHORES
Practice Address - State:FL
Practice Address - Zip Code:33138-2310
Practice Address - Country:US
Practice Address - Phone:305-757-8040
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-12-28
Last Update Date:2017-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME82129208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty