Provider Demographics
NPI:1902977663
Name:FAILLACE, ROGERIO S (MD)
Entity Type:Individual
Prefix:
First Name:ROGERIO
Middle Name:S
Last Name:FAILLACE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1951 SW 172 AVENUE
Mailing Address - Street 2:SUITE 304
Mailing Address - City:MIRAMAR
Mailing Address - State:FL
Mailing Address - Zip Code:33029
Mailing Address - Country:US
Mailing Address - Phone:954-441-1144
Mailing Address - Fax:954-441-4404
Practice Address - Street 1:1951 SW 172 AVE
Practice Address - Street 2:SUITE 304
Practice Address - City:MIRAMAR
Practice Address - State:FL
Practice Address - Zip Code:33029
Practice Address - Country:US
Practice Address - Phone:954-441-1144
Practice Address - Fax:954-441-4404
Is Sole Proprietor?:No
Enumeration Date:2006-11-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 77924208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL259184700Medicaid
H19080Medicare UPIN