Basic Information
| Provider Information | |||||||||
| NPI: | 1700015716 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | AYALA-HAEDO | ||||||||
| FirstName: | JUAN | ||||||||
| MiddleName: | ALFREDO | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6233 N UNIVERSITY DRIVE | ||||||||
| Address2: | |||||||||
| City: | TAMARAC | ||||||||
| State: | FL | ||||||||
| PostalCode: | 333214022 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9547210000 | ||||||||
| FaxNumber: | 9547216308 | ||||||||
| Practice Location | |||||||||
| Address1: | 900 NW 17TH ST | ||||||||
| Address2: | |||||||||
| City: | MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331361119 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3052432020 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/11/2009 | ||||||||
| LastUpdateDate: | 06/26/2017 | ||||||||
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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 | 208600000X | R71638 | AZ | N | Allopathic & Osteopathic Physicians | Surgery | 207W00000X | ME120847 | FL | Y | Allopathic & Osteopathic Physicians | Ophthalmology |
ID Information
| ID | Type | State | Issuer | Description | 012474000 | 05 | FL | MEDICAID |