Provider Demographics
NPI:1801451331
Name:SEGURA IGARZA, DAVID
Entity type:Individual
Prefix:MR
First Name:DAVID
Middle Name:
Last Name:SEGURA IGARZA
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 1:445 SW 63RD AVE
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33144-3844
Mailing Address - Country:US
Mailing Address - Phone:786-908-2168
Mailing Address - Fax:
Practice Address - Street 1:381 N KROME AVE STE 206
Practice Address - Street 2:
Practice Address - City:HOMESTEAD
Practice Address - State:FL
Practice Address - Zip Code:33030-6047
Practice Address - Country:US
Practice Address - Phone:776-410-8922
Practice Address - Fax:866-223-8328
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-09
Last Update Date:2019-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-18-67657106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL021498000Medicaid