1194836825 NPI number — DR. MARIEL GONZALEZ-MENDOZA MD

Table of content: DR. MARIEL GONZALEZ-MENDOZA MD (NPI 1194836825)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194836825 NPI number — DR. MARIEL GONZALEZ-MENDOZA MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GONZALEZ-MENDOZA
Provider First Name:
MARIEL
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

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:
1194836825
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/09/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
601 S HARBOUR ISLAND BLVD STE 200
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TAMPA
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33602-5925
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
800-480-5243
Provider Business Mailing Address Fax Number:
800-928-7449

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1305 CLEVELAND AVE STE G
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WILDWOOD
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34785-3605
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
352-913-2145
Provider Business Practice Location Address Fax Number:
352-913-2146
Provider Enumeration Date:
08/31/2006

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: 207Q00000X , with the licence number:  ME90507 , 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: 95554 . This is a "BCBS OF FLORIDA" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: AE544S . This is a "PTAN" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 107467800 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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