Provider Demographics
NPI:1194962126
Name:MENDIVIL, MIRIAM (OD)
Entity type:Individual
Prefix:
First Name:MIRIAM
Middle Name:
Last Name:MENDIVIL
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3180 SW 129TH AVE
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33175-2508
Mailing Address - Country:US
Mailing Address - Phone:305-905-9184
Mailing Address - Fax:
Practice Address - Street 1:5438 SW 8TH ST
Practice Address - Street 2:
Practice Address - City:CORAL GABLES
Practice Address - State:FL
Practice Address - Zip Code:33134-2267
Practice Address - Country:US
Practice Address - Phone:305-444-8676
Practice Address - Fax:305-444-5181
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-13
Last Update Date:2023-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC 4038152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist