Provider Demographics
NPI:1952667834
Name:CARLOS ALBERTO LISTA-ENSENAT MD PA
Entity Type:Organization
Organization Name:CARLOS ALBERTO LISTA-ENSENAT MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CARLOS
Authorized Official - Middle Name:A
Authorized Official - Last Name:LISTA-ENSENAT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:786-237-3070
Mailing Address - Street 1:12320 QUAIL ROOST DR
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33177-4930
Mailing Address - Country:US
Mailing Address - Phone:786-237-3070
Mailing Address - Fax:786-430-8198
Practice Address - Street 1:12320 QUAIL ROOST DR
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33177-4930
Practice Address - Country:US
Practice Address - Phone:786-237-3070
Practice Address - Fax:786-430-8198
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-05
Last Update Date:2016-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME109021207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL=========OtherFEDERAL TAX ID