Basic Information
| Provider Information | |||||||||
| NPI: | 1558335885 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOLIVAR | ||||||||
| FirstName: | JUAN | ||||||||
| MiddleName: | MANUEL | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3200 SW 60TH CT | ||||||||
| Address2: | |||||||||
| City: | MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331554000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3056628301 | ||||||||
| FaxNumber: | 3056628304 | ||||||||
| Practice Location | |||||||||
| Address1: | 50 W STUTERVANT STREET | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328064000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4076496907 | ||||||||
| FaxNumber: | 4074812035 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/14/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080P0202X | ME75602 | FL | Y | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Cardiology |
ID Information
| ID | Type | State | Issuer | Description | 273499100 | 05 | FL | MEDICAID |