Provider Demographics
NPI:1649874868
Name:MUSTELIER POMARES, ILEANA (MD)
Entity type:Individual
Prefix:DR
First Name:ILEANA
Middle Name:
Last Name:MUSTELIER POMARES
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6100 BLUE LAGOON DR STE 365
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33126-7010
Mailing Address - Country:US
Mailing Address - Phone:786-322-7333
Mailing Address - Fax:786-347-5022
Practice Address - Street 1:3805 W 20TH AVE STE 105
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33012-4532
Practice Address - Country:US
Practice Address - Phone:305-557-2277
Practice Address - Fax:786-621-7818
Is Sole Proprietor?:No
Enumeration Date:2020-11-29
Last Update Date:2022-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRN9264333163WG0000X
PR022102207Q00000X
FLACN1318207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL111776200Medicaid