Provider Demographics
NPI:1194999227
Name:CAMACHO, IVAN DARIO (MD)
Entity type:Individual
Prefix:DR
First Name:IVAN
Middle Name:DARIO
Last Name:CAMACHO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:79 SW 12TH ST PH 3907
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33130-5215
Mailing Address - Country:US
Mailing Address - Phone:305-987-9375
Mailing Address - Fax:
Practice Address - Street 1:1600 NW 10TH AVE # 2023A
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33136-1015
Practice Address - Country:US
Practice Address - Phone:305-243-4472
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-18
Last Update Date:2014-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME109790207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology