Provider Demographics
NPI:1629104351
Name:DELORES MACKSOUD MD PA
Entity Type:Organization
Organization Name:DELORES MACKSOUD MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:DELORES
Authorized Official - Middle Name:
Authorized Official - Last Name:MACKSOUD
Authorized Official - Suffix:
Authorized Official - Credentials:MD PA
Authorized Official - Phone:305-251-1373
Mailing Address - Street 1:12001 SW 128TH CT
Mailing Address - Street 2:SUITE 205
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33186-4664
Mailing Address - Country:US
Mailing Address - Phone:305-251-1373
Mailing Address - Fax:305-252-6790
Practice Address - Street 1:12001 SW 128TH CT
Practice Address - Street 2:SUITE 205
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33186-4664
Practice Address - Country:US
Practice Address - Phone:305-251-1373
Practice Address - Fax:305-252-6790
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-26
Last Update Date:2016-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME00517162084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL049326100Medicaid
FL04892UMedicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER
FLD82326Medicare UPIN
FL04892BMedicare ID - Type Unspecified