Provider Demographics
NPI:1073253084
Name:LAVELANET, MARIO EMMANUEL (MD)
Entity Type:Individual
Prefix:
First Name:MARIO
Middle Name:EMMANUEL
Last Name:LAVELANET
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1089 PROVIDENCE LN
Mailing Address - Street 2:
Mailing Address - City:OVIEDO
Mailing Address - State:FL
Mailing Address - Zip Code:32765-7065
Mailing Address - Country:US
Mailing Address - Phone:718-795-7746
Mailing Address - Fax:
Practice Address - Street 1:6000 49TH ST N
Practice Address - Street 2:
Practice Address - City:SAINT PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33709-2114
Practice Address - Country:US
Practice Address - Phone:727-521-5057
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-29
Last Update Date:2022-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program