Provider Demographics
NPI:1770932428
Name:AGUDELO-URIBE, SUSANA (MD)
Entity type:Individual
Prefix:MS
First Name:SUSANA
Middle Name:
Last Name:AGUDELO-URIBE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MS
Other - First Name:SUSANA
Other - Middle Name:
Other - Last Name:AGUDELO-URIBE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:1611 NW 12TH AVE
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33136-1005
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1611 NW 12TH AVE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33136-1005
Practice Address - Country:US
Practice Address - Phone:314-624-4601
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-03
Last Update Date:2023-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME164445208000000X
VA0101263271208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics