Provider Demographics
NPI:1104817584
Name:ESPAILLAT, IVAN R (MD)
Entity type:Individual
Prefix:MR
First Name:IVAN
Middle Name:R
Last Name:ESPAILLAT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 440728
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33144-0728
Mailing Address - Country:US
Mailing Address - Phone:305-234-8264
Mailing Address - Fax:305-255-1752
Practice Address - Street 1:12002 SW 128TH CT
Practice Address - Street 2:SUITE 204
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33186-4639
Practice Address - Country:US
Practice Address - Phone:305-234-8264
Practice Address - Fax:305-255-1752
Is Sole Proprietor?:No
Enumeration Date:2005-11-03
Last Update Date:2011-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME92158207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL275149600Medicaid
FL275149600Medicaid
FLI35640Medicare UPIN