Provider Demographics
NPI:1881639458
Name:PEDOUSSAUT, MARYSE ANNE (MD)
Entity Type:Individual
Prefix:MRS
First Name:MARYSE
Middle Name:ANNE
Last Name:PEDOUSSAUT
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 1:800 SW 108TH AVENUE, SUITE 100
Mailing Address - Street 2:
Mailing Address - City:MIAMI LAKES
Mailing Address - State:FL
Mailing Address - Zip Code:33014-6540
Mailing Address - Country:US
Mailing Address - Phone:305-348-3627
Mailing Address - Fax:305-348-4261
Practice Address - Street 1:800 SW 108TH AVE STE 100
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33174
Practice Address - Country:US
Practice Address - Phone:305-348-3627
Practice Address - Fax:305-348-4261
Is Sole Proprietor?:No
Enumeration Date:2006-06-18
Last Update Date:2018-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 82118207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL2633906Medicaid
E7246ZMedicare ID - Type Unspecified
FLH58386Medicare UPIN