Provider Demographics
NPI:1104327600
Name:BAEZ SERPA, ERNESTO A
Entity type:Individual
Prefix:
First Name:ERNESTO
Middle Name:A
Last Name:BAEZ SERPA
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 1:12340 SW 205TH ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33177-5656
Mailing Address - Country:US
Mailing Address - Phone:305-519-6424
Mailing Address - Fax:
Practice Address - Street 1:4530 SW 68TH COURT CIR APT 7
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33155-6871
Practice Address - Country:US
Practice Address - Phone:305-519-6424
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-21
Last Update Date:2024-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL106S00000X
FL104852225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician