Provider Demographics
NPI:1194782391
Name:MONTILLA, DESALY
Entity type:Individual
Prefix:MRS
First Name:DESALY
Middle Name:
Last Name:MONTILLA
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:DESALY
Other - Middle Name:
Other - Last Name:GONZALEZ
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:8525 SW 92 STREET
Mailing Address - Street 2:SUITE B 4
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33156-7374
Mailing Address - Country:US
Mailing Address - Phone:305-279-7446
Mailing Address - Fax:305-598-8753
Practice Address - Street 1:8525 SW 92 STREET
Practice Address - Street 2:SUITE B 4
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33156-7374
Practice Address - Country:US
Practice Address - Phone:305-279-7446
Practice Address - Fax:305-598-8753
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-01
Last Update Date:2010-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME38945207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
D64714Medicare UPIN
FL94478Medicare ID - Type Unspecified