Provider Demographics
NPI:1457347957
Name:TAMAYO, EDMUNDO RAFAEL (MD)
Entity Type:Individual
Prefix:
First Name:EDMUNDO
Middle Name:RAFAEL
Last Name:TAMAYO
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 1:9037 BISCAYNE BOULEVARD
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33138-3221
Mailing Address - Country:US
Mailing Address - Phone:305-835-2797
Mailing Address - Fax:305-835-6228
Practice Address - Street 1:1190 NW 95TH ST
Practice Address - Street 2:SUITE 107
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33150-2063
Practice Address - Country:US
Practice Address - Phone:305-835-2797
Practice Address - Fax:305-835-6228
Is Sole Proprietor?:No
Enumeration Date:2005-09-21
Last Update Date:2017-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME67715207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL379231500Medicaid
FL379231500Medicaid
26618ZMedicare ID - Type Unspecified