1477650695 NPI number — DR. GISELE VICTOR MARDY MD

Table of content: DR. GISELE VICTOR MARDY MD (NPI 1477650695)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477650695 NPI number — DR. GISELE VICTOR MARDY MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MARDY
Provider First Name:
GISELE
Provider Middle Name:
VICTOR
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:
1477650695
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/20/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9299W 152TH ST #207
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MIAMI
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33157
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
305-253-6654
Provider Business Mailing Address Fax Number:
305-235-3501

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9299 SW 152TH ST
Provider Second Line Business Practice Location Address:
#207
Provider Business Practice Location Address City Name:
MIAMI
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33157
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
305-253-6654
Provider Business Practice Location Address Fax Number:
305-235-3501
Provider Enumeration Date:
09/20/2006

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: 208000000X , with the licence number:  ME0070216 , 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: 250371900 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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