Provider Demographics
NPI:1154498772
Name:FIALLOS, MARIANO R (MD)
Entity Type:Individual
Prefix:DR
First Name:MARIANO
Middle Name:R
Last Name:FIALLOS
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 1:3100 E FLETCHER AVE
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33613-4613
Mailing Address - Country:US
Mailing Address - Phone:813-467-4242
Mailing Address - Fax:813-467-4243
Practice Address - Street 1:3100 E FLETCHER AVE
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33613-4613
Practice Address - Country:US
Practice Address - Phone:813-467-4242
Practice Address - Fax:813-467-4243
Is Sole Proprietor?:No
Enumeration Date:2006-11-29
Last Update Date:2021-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME00618852080A0000X, 2080P0203X, 208M00000X
FLME61885208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
No2080P0203XAllopathic & Osteopathic PhysiciansPediatricsPediatric Critical Care Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL11314867OtherCAQH
FL254343500Medicaid
FLF09310OtherUPIN
FL43953OtherBLUE CROSS