Provider Demographics
NPI:1245897701
Name:DEARRIBA, EDGARDO
Entity type:Individual
Prefix:
First Name:EDGARDO
Middle Name:
Last Name:DEARRIBA
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9615 SW 24TH ST APT A124
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33165-8081
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7306 SW 117TH AVE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33183-3804
Practice Address - Country:US
Practice Address - Phone:305-220-0220
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-21
Last Update Date:2025-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-19-83572106S00000X
FLRN-9364398163W00000X
FLAPRN-11021754363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No163W00000XNursing Service ProvidersRegistered Nurse