1659334670 NPI number — RENE N MAYORGA M D P A

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1659334670 NPI number — RENE N MAYORGA M D P A

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RENE N MAYORGA M D P A
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
COUNTRY WALK FAMILY MEDICINE
Provider Other Organization Name Type Code:
3
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:
1659334670
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/22/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
14261 SW 120TH ST
Provider Second Line Business Mailing Address:
SUITE 110
Provider Business Mailing Address City Name:
MIAMI
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33186-7270
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
305-378-1302
Provider Business Mailing Address Fax Number:
305-378-1311

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
14261 SW 120TH ST
Provider Second Line Business Practice Location Address:
SUITE 110
Provider Business Practice Location Address City Name:
MIAMI
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33186-7270
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
305-378-1302
Provider Business Practice Location Address Fax Number:
305-378-1311
Provider Enumeration Date:
04/10/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MAYORGA
Authorized Official First Name:
RENE
Authorized Official Middle Name:
N
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
305-378-1302

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  ME54068 , 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: 14292 . This is a "VISTA" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 003349 . This is a "NEIGHBORHOOD HEALTH PART" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 2132789 . This is a "AETNA" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: F00138402601 . This is a "NEIGBORHOOD HEALTH" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 061439400 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 08688 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 0170072 . This is a "UNITED" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 101635 . This is a "AVMED" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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