Provider Demographics
NPI:1497860928
Name:BOUZA, MANUEL (MD)
Entity type:Individual
Prefix:DR
First Name:MANUEL
Middle Name:
Last Name:BOUZA
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 1:690 E 25TH ST
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33013-3815
Mailing Address - Country:US
Mailing Address - Phone:305-696-0331
Mailing Address - Fax:305-696-1239
Practice Address - Street 1:690 E 25TH ST
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33013-3815
Practice Address - Country:US
Practice Address - Phone:305-696-0331
Practice Address - Fax:305-696-1239
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-21
Last Update Date:2008-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0052013174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL064503600Medicaid
FL064503600Medicaid
FL11435Medicare ID - Type Unspecified