Provider Demographics
NPI:1891716908
Name:O' BOURKE, ALBA MARINA (MD)
Entity Type:Individual
Prefix:
First Name:ALBA MARINA
Middle Name:
Last Name:O' BOURKE
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 1:1611 CORAL GATE DR
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33145-1837
Mailing Address - Country:US
Mailing Address - Phone:305-441-9362
Mailing Address - Fax:305-441-9362
Practice Address - Street 1:4155 SW 130TH AVE
Practice Address - Street 2:#102
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33175-3414
Practice Address - Country:US
Practice Address - Phone:305-223-3580
Practice Address - Fax:305-223-3582
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-22
Last Update Date:2021-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME90672208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLI15763Medicare UPIN
FLU3113Medicare ID - Type Unspecified