Provider Demographics
NPI:1699710905
Name:FANILLA, EDUARDO (MD)
Entity type:Individual
Prefix:
First Name:EDUARDO
Middle Name:
Last Name:FANILLA
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 1:12301 SW 124TH CT
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33186-5476
Mailing Address - Country:US
Mailing Address - Phone:786-573-3152
Mailing Address - Fax:786-573-3152
Practice Address - Street 1:6963 SW 117TH AVE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33183-2803
Practice Address - Country:US
Practice Address - Phone:786-595-3225
Practice Address - Fax:786-595-7812
Is Sole Proprietor?:No
Enumeration Date:2006-06-19
Last Update Date:2024-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME827872080P0204X, 2080P0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0204XAllopathic & Osteopathic PhysiciansPediatricsPediatric Emergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL262088000Medicaid