Provider Demographics
NPI:1033704580
Name:MIJARES, DANIEL CARLOS
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:CARLOS
Last Name:MIJARES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7700 SW 176TH ST
Mailing Address - Street 2:
Mailing Address - City:PALMETTO BAY
Mailing Address - State:FL
Mailing Address - Zip Code:33157-6244
Mailing Address - Country:US
Mailing Address - Phone:786-564-2670
Mailing Address - Fax:
Practice Address - Street 1:437 N KROME AVE
Practice Address - Street 2:
Practice Address - City:HOMESTEAD
Practice Address - State:FL
Practice Address - Zip Code:33030-6040
Practice Address - Country:US
Practice Address - Phone:786-378-8277
Practice Address - Fax:305-328-4089
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-06
Last Update Date:2024-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9113118363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant