Provider Demographics
NPI:1720091960
Name:ALICEA, EDGARDO (MD)
Entity Type:Individual
Prefix:DR
First Name:EDGARDO
Middle Name:
Last Name:ALICEA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:EDGARDO
Other - Middle Name:
Other - Last Name:ALICEA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:14750 NW 44TH CT
Mailing Address - Street 2:
Mailing Address - City:OPA LOCKA
Mailing Address - State:FL
Mailing Address - Zip Code:33054-2304
Mailing Address - Country:US
Mailing Address - Phone:305-953-2323
Mailing Address - Fax:
Practice Address - Street 1:14750 NW 44TH CT
Practice Address - Street 2:
Practice Address - City:OPA LOCKA
Practice Address - State:FL
Practice Address - Zip Code:33054-2304
Practice Address - Country:US
Practice Address - Phone:305-953-2323
Practice Address - Fax:305-953-2308
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-15
Last Update Date:2020-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01059115A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine