Provider Demographics
NPI:1174541304
Name:DSIDA, STEPHEN R (LP, CPO)
Entity type:Individual
Prefix:MR
First Name:STEPHEN
Middle Name:R
Last Name:DSIDA
Suffix:
Gender:M
Credentials:LP, CPO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13704 SW 13TH ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33184-2701
Mailing Address - Country:US
Mailing Address - Phone:305-585-6265
Mailing Address - Fax:305-585-2675
Practice Address - Street 1:1611 NW 12TH AVE
Practice Address - Street 2:P & O LAB, REHAB, ROOM 129
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33136-1005
Practice Address - Country:US
Practice Address - Phone:305-585-6265
Practice Address - Fax:305-585-2675
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2013-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPRO 9174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist