Provider Demographics
NPI:1790914786
Name:SICILIA, PABLO (MR)
Entity Type:Individual
Prefix:MR
First Name:PABLO
Middle Name:
Last Name:SICILIA
Suffix:
Gender:M
Credentials:MR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:711 NW 23RD AVE
Mailing Address - Street 2:SUITE 204
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33125-3298
Mailing Address - Country:US
Mailing Address - Phone:305-644-4464
Mailing Address - Fax:305-644-4464
Practice Address - Street 1:711 NW 23RD AVE
Practice Address - Street 2:SUITE 204
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33125-3298
Practice Address - Country:US
Practice Address - Phone:305-644-4464
Practice Address - Fax:305-644-4464
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-10
Last Update Date:2011-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA51624261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center