1750329546 NPI number — MARIO R REALE M.D.

Table of content: MARIO R REALE M.D. (NPI 1750329546)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750329546 NPI number — MARIO R REALE M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
REALE
Provider First Name:
MARIO
Provider Middle Name:
R
Provider Name Prefix Text:
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:
1750329546
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6731 AVENIDA DE GALVEZ
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NAVARRE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32566-8919
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
850-936-4216
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4900 BAYOU BLVD
Provider Second Line Business Practice Location Address:
SUITE 205
Provider Business Practice Location Address City Name:
PENSACOLA
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32503-2525
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
850-476-2387
Provider Business Practice Location Address Fax Number:
850-476-9707
Provider Enumeration Date:
06/03/2006

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: 2080N0001X , with the licence number:  ME 80770 , 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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