Provider Demographics
NPI:1881011260
Name:BAHAMONDE, EMMANUEL ISAAC (MD)
Entity Type:Individual
Prefix:
First Name:EMMANUEL
Middle Name:ISAAC
Last Name:BAHAMONDE
Suffix:
Gender:M
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 PARK CENTRE BLVD STE 134
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33169-5373
Mailing Address - Country:US
Mailing Address - Phone:305-651-3261
Mailing Address - Fax:
Practice Address - Street 1:16401 NW 2ND AVE STE 203
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33169-6036
Practice Address - Country:US
Practice Address - Phone:305-999-0009
Practice Address - Fax:305-945-7136
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-24
Last Update Date:2023-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR19455390200000X
FLME139931207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program