Provider Demographics
NPI:1659357358
Name:BELLAMAR MEDICAL OFFICE
Entity Type:Organization
Organization Name:BELLAMAR MEDICAL OFFICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOSE
Authorized Official - Middle Name:
Authorized Official - Last Name:RIVERA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-418-3855
Mailing Address - Street 1:4811 NW 79TH AVE
Mailing Address - Street 2:SUITE 2
Mailing Address - City:DORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33166-5438
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4811 NW 79TH AVE
Practice Address - Street 2:SUITE 2
Practice Address - City:DORAL
Practice Address - State:FL
Practice Address - Zip Code:33166-5438
Practice Address - Country:US
Practice Address - Phone:305-418-3855
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME68564174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK6207Medicare ID - Type Unspecified