1528770807 NPI number — MARIANA VICTORIA GONZALEZ MITIDIERI PHARMD

Table of content: MARIANA VICTORIA GONZALEZ MITIDIERI PHARMD (NPI 1528770807)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1528770807 NPI number — MARIANA VICTORIA GONZALEZ MITIDIERI PHARMD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GONZALEZ MITIDIERI
Provider First Name:
MARIANA
Provider Middle Name:
VICTORIA
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PHARMD
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:
1528770807
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/19/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
761 ASHWORTH OVERLOOK DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
APOPKA
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32712-3348
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
787-640-1017
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1401 S HIAWASSEE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ORLANDO
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32835-5715
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
407-295-2333
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/19/2022

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: 183500000X , with the licence number:  PS65242 , 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)





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