Provider Demographics
NPI:1801314190
Name:EAST MEDICAL OFFICE
Entity type:Organization
Organization Name:EAST MEDICAL OFFICE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRECIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:BOASC
Authorized Official - Suffix:SR
Authorized Official - Credentials:
Authorized Official - Phone:305-510-1190
Mailing Address - Street 1:3778 W 12TH AVE
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33012-4126
Mailing Address - Country:US
Mailing Address - Phone:305-510-1190
Mailing Address - Fax:
Practice Address - Street 1:3778 W 12TH AVE
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33012-4126
Practice Address - Country:US
Practice Address - Phone:305-510-1190
Practice Address - Fax:786-534-7238
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-06
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLHCC11133208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLHCC1133OtherHEALTHCARE CLINIC
FLHCC1133OtherHEALTHCARE CLINIC