Provider Demographics
NPI:1124230081
Name:TUDELA, MARIO (MA-1936687)
Entity Type:Individual
Prefix:MR
First Name:MARIO
Middle Name:
Last Name:TUDELA
Suffix:
Gender:M
Credentials:MA-1936687
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6348 W 22ND LN
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33016-3925
Mailing Address - Country:US
Mailing Address - Phone:305-557-8780
Mailing Address - Fax:
Practice Address - Street 1:620 NW 33RD AVE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33125-4106
Practice Address - Country:US
Practice Address - Phone:305-646-0062
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA1936687172M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172M00000XOther Service ProvidersMechanotherapist