Provider Demographics
NPI:1033744925
Name:FLORIDA RADIOLOGY IMAGING AT LAKE MARY, LLC
Entity Type:Organization
Organization Name:FLORIDA RADIOLOGY IMAGING AT LAKE MARY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:MAZERES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-200-2355
Mailing Address - Street 1:900 WINDERLEY PL STE 2100
Mailing Address - Street 2:
Mailing Address - City:MAITLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32751-4191
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1480 W ORANGE BLOSSOM TRL
Practice Address - Street 2:
Practice Address - City:APOPKA
Practice Address - State:FL
Practice Address - Zip Code:32712-2637
Practice Address - Country:US
Practice Address - Phone:407-200-5440
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FLORIDA RADIOLOGY IMAGING AT LAKE MARY, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-03-11
Last Update Date:2020-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085B0100XAllopathic & Osteopathic PhysiciansRadiologyBody ImagingGroup - Multi-Specialty