Provider Demographics
NPI:1750600516
Name:PLASENCIA, MIRTA
Entity type:Individual
Prefix:MISS
First Name:MIRTA
Middle Name:
Last Name:PLASENCIA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4445 W 16TH AVE STE 602
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33012-2960
Mailing Address - Country:US
Mailing Address - Phone:786-334-5663
Mailing Address - Fax:786-786-4315
Practice Address - Street 1:4445 W 16TH AVE STE 602
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33012-2960
Practice Address - Country:US
Practice Address - Phone:786-334-5663
Practice Address - Fax:786-786-4315
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-19
Last Update Date:2023-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA58262261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL271834196OtherITIN