Provider Demographics
NPI:1891917910
Name:DE LA MAZA, SEBASTIAN (CHILD ADOLESCENT AND)
Entity Type:Individual
Prefix:MR
First Name:SEBASTIAN
Middle Name:
Last Name:DE LA MAZA
Suffix:
Gender:M
Credentials:CHILD ADOLESCENT AND
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8740 N KENDALL DR
Mailing Address - Street 2:SUITE 206
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33176
Mailing Address - Country:US
Mailing Address - Phone:305-595-0189
Mailing Address - Fax:305-595-0189
Practice Address - Street 1:8740 N KENDALL DR
Practice Address - Street 2:SUITE 206
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33176
Practice Address - Country:US
Practice Address - Phone:305-595-0189
Practice Address - Fax:305-595-0189
Is Sole Proprietor?:No
Enumeration Date:2007-05-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME00348382084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL95380Medicare ID - Type Unspecified
D27863Medicare UPIN