Provider Demographics
NPI:1194779959
Name:PETRICK, MARIZA SOUZA (MD)
Entity type:Individual
Prefix:DR
First Name:MARIZA
Middle Name:SOUZA
Last Name:PETRICK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4960 SW 72ND AVE
Mailing Address - Street 2:SUITE 406
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33155-5544
Mailing Address - Country:US
Mailing Address - Phone:305-662-5200
Mailing Address - Fax:305-284-7948
Practice Address - Street 1:440 W 49TH ST
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33012-3603
Practice Address - Country:US
Practice Address - Phone:305-828-5700
Practice Address - Fax:305-461-5911
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0054500208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLME0054500OtherMEDICAL LICENSE
FLME0054500OtherMEDICAL LICENSE
FL09220Medicare ID - Type Unspecified
FLF01252Medicare UPIN