Provider Demographics
NPI:1558377382
Name:DE URRESTI, MIREN ALAI (MD)
Entity type:Individual
Prefix:
First Name:MIREN
Middle Name:ALAI
Last Name:DE URRESTI
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 1:15475 SW 42ND TER
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33185-4543
Mailing Address - Country:US
Mailing Address - Phone:305-551-5617
Mailing Address - Fax:305-551-0999
Practice Address - Street 1:13055 SW 42ND ST STE 108
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33175
Practice Address - Country:US
Practice Address - Phone:305-204-9195
Practice Address - Fax:305-204-9196
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2018-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0072002207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL252784700Medicaid
FL42374ZMedicare ID - Type Unspecified