Basic Information
| Provider Information | |||||||||
| NPI: | 1922031095 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | AMENDOLA | ||||||||
| FirstName: | MARCO | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5995 SW 71ST ST | ||||||||
| Address2: | |||||||||
| City: | SOUTH MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331433531 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3056696833 | ||||||||
| FaxNumber: | 3056664030 | ||||||||
| Practice Location | |||||||||
| Address1: | 1611 NW 12TH AVE | ||||||||
| Address2: | BOX 016960 (M851) | ||||||||
| City: | MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331361005 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3052436358 | ||||||||
| FaxNumber: | 3052438470 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/09/2006 | ||||||||
| LastUpdateDate: | 08/08/2018 | ||||||||
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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 | 2085B0100X | ME58412 | FL | Y | Allopathic & Osteopathic Physicians | Radiology | Body Imaging |
ID Information
| ID | Type | State | Issuer | Description | 0616028-00 | 05 | FL | MEDICAID |