1174573059 NPI number — DR. JAMES JEROME MAHONEY JR. MD

Table of content: DR. JAMES JEROME MAHONEY JR. MD (NPI 1174573059)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174573059 NPI number — DR. JAMES JEROME MAHONEY JR. MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MAHONEY
Provider First Name:
JAMES
Provider Middle Name:
JEROME
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
JR.
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1174573059
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3112 WINCHESTER DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COCOA
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32926-5860
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
305-797-0303
Provider Business Mailing Address Fax Number:
305-293-4813

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1350 DOUGLAS CIR
Provider Second Line Business Practice Location Address:
BMA DIALYSIS 1122 KEYS PLAZA
Provider Business Practice Location Address City Name:
KEY WEST
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33040-4536
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
305-797-0303
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/11/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207RN0300X , with the licence number:  ME20354 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 01196 . This is a "BLUE SHIELD" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".