Provider Demographics
NPI:1144385592
Name:HIDALGO, AUSBERTO BIENVENIDO
Entity type:Individual
Prefix:DR
First Name:AUSBERTO
Middle Name:BIENVENIDO
Last Name:HIDALGO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:AUSBERTO
Other - Middle Name:B
Other - Last Name:HIDALGO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:302 NW 179TH AVENUE
Mailing Address - Street 2:SUITE 103
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33029-2810
Mailing Address - Country:US
Mailing Address - Phone:954-442-8380
Mailing Address - Fax:954-442-8661
Practice Address - Street 1:302 NW 179TH AVENUE
Practice Address - Street 2:SUITE 103
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33029-2810
Practice Address - Country:US
Practice Address - Phone:954-442-8380
Practice Address - Fax:954-442-8661
Is Sole Proprietor?:No
Enumeration Date:2006-12-26
Last Update Date:2015-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0053208208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL049046600Medicaid
FL07589AMedicare ID - Type Unspecified
FL049046600Medicaid