Basic Information
| Provider Information | |||||||||
| NPI: | 1982932422 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DVAMC MIAMI | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | BRUCE W. CARTER MEDICAL CENTER | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1201 NW 16TH ST | ||||||||
| Address2: | MAILSTOP 112 | ||||||||
| City: | MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331251624 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3055757000 | ||||||||
| FaxNumber: | 3055757234 | ||||||||
| Practice Location | |||||||||
| Address1: | 1201 NW 16TH ST | ||||||||
| Address2: | MAILSTOP 112 | ||||||||
| City: | MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331251624 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3055757000 | ||||||||
| FaxNumber: | 3055757234 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/20/2009 | ||||||||
| LastUpdateDate: | 11/20/2009 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | VELA | ||||||||
| AuthorizedOfficialFirstName: | NATHAN | ||||||||
| AuthorizedOfficialMiddleName: | DANIEL | ||||||||
| AuthorizedOfficialTitleorPosition: | PODIATRIC SURGICAL RESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3055757000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | D.P.M. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QV0200X | PR174 | FL | Y | Ambulatory Health Care Facilities | Clinic/Center | VA |
No ID Information.