Provider Demographics
NPI:1952839458
Name:BACA, MAURICIO JOSE (MD)
Entity Type:Individual
Prefix:DR
First Name:MAURICIO
Middle Name:JOSE
Last Name:BACA
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 1:7333 SW 122ND PL
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33183-3628
Mailing Address - Country:US
Mailing Address - Phone:786-390-3675
Mailing Address - Fax:
Practice Address - Street 1:8900 N KENDALL DR
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33176-2118
Practice Address - Country:US
Practice Address - Phone:786-596-1960
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-28
Last Update Date:2020-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME143840207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLTRN24717OtherRESIDENT PHYSICIAN