Provider Demographics
NPI:1740637073
Name:CORDOVA CABALLERO, DIMITRI
Entity type:Individual
Prefix:
First Name:DIMITRI
Middle Name:
Last Name:CORDOVA CABALLERO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2001 PALM BEACH LAKES BLVD STE 400
Mailing Address - Street 2:
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33409-6516
Mailing Address - Country:US
Mailing Address - Phone:561-420-8544
Mailing Address - Fax:561-712-8886
Practice Address - Street 1:14770 SW 176TH ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33187-6714
Practice Address - Country:US
Practice Address - Phone:786-366-7785
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-17
Last Update Date:2019-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR19456208D00000X
FLACN1021207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice