Basic Information
Provider Information | |||||||||
NPI: | 1912154865 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | CALDERON AMEZQUITA | ||||||||
FirstName: | YEMAL | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | CALDERON AMEZQUITA | ||||||||
OtherFirstName: | YEMAL | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | MD | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 3061 SW 192ND AVE | ||||||||
Address2: |   | ||||||||
City: | MIRAMAR | ||||||||
State: | FL | ||||||||
PostalCode: | 330295826 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7873471735 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 2001 W 68TH ST | ||||||||
Address2: |   | ||||||||
City: | HIALEAH | ||||||||
State: | FL | ||||||||
PostalCode: | 330161801 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3058235000 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/22/2008 | ||||||||
LastUpdateDate: | 05/01/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | ME111019 | FL | Y |   | Allopathic & Osteopathic Physicians | Emergency Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 1912154865 | 05 | PR |   | MEDICAID |