Provider Demographics
NPI:1881924157
Name:AMISIAL, EDY (MD)
Entity type:Individual
Prefix:DR
First Name:EDY
Middle Name:
Last Name:AMISIAL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1380 NE MIAMI GARDENS DR STE 140B
Mailing Address - Street 2:
Mailing Address - City:NORTH MIAMI BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33179-4744
Mailing Address - Country:US
Mailing Address - Phone:786-657-2269
Mailing Address - Fax:786-955-6972
Practice Address - Street 1:1380 NE MIAMI GARDENS DR STE 140B
Practice Address - Street 2:
Practice Address - City:NORTH MIAMI BEACH
Practice Address - State:FL
Practice Address - Zip Code:33179-4744
Practice Address - Country:US
Practice Address - Phone:786-657-2269
Practice Address - Fax:786-955-6972
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-08
Last Update Date:2024-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME108552207V00000X, 207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL004060500Medicaid
FLFR961ZMedicare PIN