Provider Demographics
NPI:1619135175
Name:MINA, MICHELLE RUIZ (MD)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:RUIZ
Last Name:MINA
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 1:401 NORTH MICHIGAN AVE,
Mailing Address - Street 2:STE 1200
Mailing Address - City:CHICAGO
Mailing Address - State:FL
Mailing Address - Zip Code:60611-4264
Mailing Address - Country:US
Mailing Address - Phone:312-635-0973
Mailing Address - Fax:813-290-9691
Practice Address - Street 1:4300 ROCK ISLAND RD
Practice Address - Street 2:
Practice Address - City:LAUDERHILL
Practice Address - State:FL
Practice Address - Zip Code:33319-4528
Practice Address - Country:US
Practice Address - Phone:954-485-6144
Practice Address - Fax:954-485-6406
Is Sole Proprietor?:No
Enumeration Date:2008-05-30
Last Update Date:2015-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME110056208100000X, 2081P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLME110056OtherLICENSE
FLFO599XMedicare PIN