1619167038 NPI number — DR. ROBERTO GAUDDAH MENGUITO M.D.

Table of content: DR. ROBERTO GAUDDAH MENGUITO M.D. (NPI 1619167038)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619167038 NPI number — DR. ROBERTO GAUDDAH MENGUITO M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MENGUITO
Provider First Name:
ROBERTO
Provider Middle Name:
GAUDDAH
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
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:
1619167038
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/09/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
150 RIDGEWAY DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BRIDGEPORT
Provider Business Mailing Address State Name:
WV
Provider Business Mailing Address Postal Code:
26330-1175
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
947 TOWN CENTER DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ORANGE CITY
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32763-8361
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
386-366-5530
Provider Business Practice Location Address Fax Number:
855-936-1288
Provider Enumeration Date:
08/01/2007

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: 390200000X , with the licence number:  AS22959041564 , registered in the state of WV ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 174400000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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