Provider Demographics
NPI:1619124898
Name:DE LA MAZA, ANTONIO (MD)
Entity Type:Individual
Prefix:DR
First Name:ANTONIO
Middle Name:
Last Name:DE LA MAZA
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 1:8722 SW 212TH TER
Mailing Address - Street 2:
Mailing Address - City:CUTLER BAY
Mailing Address - State:FL
Mailing Address - Zip Code:33189-3879
Mailing Address - Country:US
Mailing Address - Phone:305-256-4509
Mailing Address - Fax:
Practice Address - Street 1:10300 SW 216TH ST
Practice Address - Street 2:
Practice Address - City:CUTLER BAY
Practice Address - State:FL
Practice Address - Zip Code:33190-1003
Practice Address - Country:US
Practice Address - Phone:305-278-6434
Practice Address - Fax:305-252-5881
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-19
Last Update Date:2011-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME# 00250262084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL001554300Medicaid
FLBCD & BS 2-29880 BOtherAETNA F92800
DH716ZMedicare PIN