Provider Demographics
NPI:1124526207
Name:POMPANO MEDICAL SPECIALTY GROUP
Entity type:Organization
Organization Name:POMPANO MEDICAL SPECIALTY GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MAYRA
Authorized Official - Middle Name:
Authorized Official - Last Name:FUENTES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:561-932-8155
Mailing Address - Street 1:2700 W ATLANTIC BLVD STE 214
Mailing Address - Street 2:
Mailing Address - City:POMPANO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33069-5727
Mailing Address - Country:US
Mailing Address - Phone:561-932-8155
Mailing Address - Fax:
Practice Address - Street 1:2700 W ATLANTIC BLVD STE 214
Practice Address - Street 2:
Practice Address - City:POMPANO BEACH
Practice Address - State:FL
Practice Address - Zip Code:33069-5727
Practice Address - Country:US
Practice Address - Phone:561-932-8155
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-24
Last Update Date:2018-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty