Provider Demographics
NPI:1083726574
Name:MARY L. DAVIGLUS
Entity Type:Organization
Organization Name:MARY L. DAVIGLUS
Other - Org Name:MARY L. DAVIGLUS, M.D.,P.A.
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:ANESTHESIOLOGIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:L
Authorized Official - Last Name:DAVIGLUS
Authorized Official - Suffix:
Authorized Official - Credentials:MD,PA
Authorized Official - Phone:407-240-6323
Mailing Address - Street 1:8751 COMMODITY CIR
Mailing Address - Street 2:SUITE 16
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32819-9027
Mailing Address - Country:US
Mailing Address - Phone:407-964-1334
Mailing Address - Fax:407-730-5917
Practice Address - Street 1:8751 COMMODITY CIR
Practice Address - Street 2:SUITE 16
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32819-9027
Practice Address - Country:US
Practice Address - Phone:407-964-1334
Practice Address - Fax:407-730-5917
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2012-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0040734261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL061862400Medicaid
FL=========OtherTIN
FL061862400Medicaid