Provider Demographics
NPI:1053784975
Name:DYNAMIC MEDICAL GROUP OF CORAL WAY
Entity type:Organization
Organization Name:DYNAMIC MEDICAL GROUP OF CORAL WAY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:IVAN
Authorized Official - Middle Name:E
Authorized Official - Last Name:BEJERANO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:786-479-6165
Mailing Address - Street 1:7221 CORAL WAY STE 206
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33155-1436
Mailing Address - Country:US
Mailing Address - Phone:786-355-3771
Mailing Address - Fax:
Practice Address - Street 1:7221 CORAL WAY STE 206
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33155-1436
Practice Address - Country:US
Practice Address - Phone:786-355-3771
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-02
Last Update Date:2015-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS13450261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service