Basic Information
Provider Information
NPI: 1972015204
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: ALVAREZ
FirstName: EDGARDO
MiddleName: A
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 14309 SW 133RD CT
Address2:  
City: MIAMI
State: FL
PostalCode: 331868327
CountryCode: US
TelephoneNumber: 7864431724
FaxNumber:  
Practice Location
Address1: 10300 SUNSET DR STE 114
Address2:  
City: MIAMI
State: FL
PostalCode: 331733038
CountryCode: US
TelephoneNumber: 3055085580
FaxNumber: 7726759100
Other Information
ProviderEnumerationDate: 10/26/2017
LastUpdateDate: 05/10/2019
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
106S00000X  Y    

No ID Information.


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