Provider Demographics
NPI:1780858258
Name:FAILLACE, HENRIETE D (MD)
Entity Type:Individual
Prefix:
First Name:HENRIETE
Middle Name:D
Last Name:FAILLACE
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 1:1000 BELLE MEADE ISLAND DR
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33138-5252
Mailing Address - Country:US
Mailing Address - Phone:305-935-2452
Mailing Address - Fax:
Practice Address - Street 1:2627 NE 203RD ST STE 101
Practice Address - Street 2:
Practice Address - City:AVENTURA
Practice Address - State:FL
Practice Address - Zip Code:33180-1945
Practice Address - Country:US
Practice Address - Phone:305-935-2452
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-16
Last Update Date:2008-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0064004208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLF67571Medicare UPIN