Provider Demographics
NPI:1154735058
Name:MIRAMAR PAIN MEDICINE, PA
Entity type:Organization
Organization Name:MIRAMAR PAIN MEDICINE, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:IGNACIO
Authorized Official - Middle Name:J
Authorized Official - Last Name:RODRIGUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:786-295-8721
Mailing Address - Street 1:1991 W 60TH ST
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33012-7504
Mailing Address - Country:US
Mailing Address - Phone:305-823-1808
Mailing Address - Fax:305-821-7186
Practice Address - Street 1:1991 W 60TH ST
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33012-7504
Practice Address - Country:US
Practice Address - Phone:305-823-1808
Practice Address - Fax:305-821-7186
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-18
Last Update Date:2015-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME61654208VP0014X, 208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL371365200Medicaid
FL1386600708OtherNPI
FL371365200Medicaid