Provider Demographics
NPI:1902973464
Name:WEST DADE PEDIATRICS
Entity Type:Organization
Organization Name:WEST DADE PEDIATRICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENTIAL
Authorized Official - Prefix:
Authorized Official - First Name:JULIO
Authorized Official - Middle Name:C
Authorized Official - Last Name:EGUSQUIZA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:305-551-1195
Mailing Address - Street 1:3220 SW 107TH AVE
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33165-3606
Mailing Address - Country:US
Mailing Address - Phone:305-551-1195
Mailing Address - Fax:305-551-1094
Practice Address - Street 1:7100 W 20TH AVE
Practice Address - Street 2:SUITE 411
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33016-1897
Practice Address - Country:US
Practice Address - Phone:305-823-0901
Practice Address - Fax:305-558-5304
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-29
Last Update Date:2018-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL268809301Medicaid
FL268809300Medicaid
FL268809301Medicaid