Provider Demographics
NPI:1689455099
Name:SUAREZ, ENRIQUE E (AGENT)
Entity Type:Individual
Prefix:
First Name:ENRIQUE
Middle Name:E
Last Name:SUAREZ
Suffix:
Gender:M
Credentials:AGENT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17400 NW 68TH AVE APT 309
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33015-4073
Mailing Address - Country:US
Mailing Address - Phone:786-252-9650
Mailing Address - Fax:
Practice Address - Street 1:6625 MIAMI LAKES DR
Practice Address - Street 2:
Practice Address - City:MIAMI LAKES
Practice Address - State:FL
Practice Address - Zip Code:33014-2708
Practice Address - Country:US
Practice Address - Phone:786-252-9650
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-11
Last Update Date:2023-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLW453314302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization