Provider Demographics
NPI:1215073283
Name:TERESA C IRIBARREN MD PA
Entity type:Organization
Organization Name:TERESA C IRIBARREN MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TERESA
Authorized Official - Middle Name:C
Authorized Official - Last Name:IRIBARREN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:786-200-1162
Mailing Address - Street 1:12955 SW 42ND ST
Mailing Address - Street 2:SUITE 12
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33175-2902
Mailing Address - Country:US
Mailing Address - Phone:305-226-5106
Mailing Address - Fax:305-226-5105
Practice Address - Street 1:12955 SW 42ND ST
Practice Address - Street 2:SUITE 12
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33175-2902
Practice Address - Country:US
Practice Address - Phone:305-226-5106
Practice Address - Fax:305-226-5105
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-29
Last Update Date:2008-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME79837174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLAF411Medicare PIN