Provider Demographics
NPI:1962644021
Name:CAMACHO, MIRTHA AMELIA
Entity Type:Individual
Prefix:MRS
First Name:MIRTHA
Middle Name:AMELIA
Last Name:CAMACHO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6227 N UNIVERSITY DR
Mailing Address - Street 2:
Mailing Address - City:TAMARAC
Mailing Address - State:FL
Mailing Address - Zip Code:33321-4022
Mailing Address - Country:US
Mailing Address - Phone:954-529-1075
Mailing Address - Fax:954-721-6308
Practice Address - Street 1:6227 N UNIVERSITY DR
Practice Address - Street 2:
Practice Address - City:TAMARAC
Practice Address - State:FL
Practice Address - Zip Code:33321-4022
Practice Address - Country:US
Practice Address - Phone:954-529-1075
Practice Address - Fax:954-721-6308
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-03
Last Update Date:2009-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDO2462156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician