Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 208D00000X | General Practice Physician | 21030 | PR |
Y | 208D00000X | General Practice Physician | ACN1096 | FL |
NPI | 1043704919 |
---|---|
Provider Name | Dr. Katia Fajardo Martinez |
First Address | Miami, FL 33184-3533 |
Second Address | Hialeah, FL 33016-5446 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 14/06/2018 |
Last Update Date | 15/10/2018 |