Provider Demographics
NPI:1174504690
Name:MEHRGUT, FABIO MARIANO (MD)
Entity Type:Individual
Prefix:MR
First Name:FABIO
Middle Name:MARIANO
Last Name:MEHRGUT
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 1:16255 SW 83RD LANE
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33193
Mailing Address - Country:US
Mailing Address - Phone:786-479-7878
Mailing Address - Fax:305-246-5880
Practice Address - Street 1:16255 SW 83RD LN
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33193-5133
Practice Address - Country:US
Practice Address - Phone:786-479-7878
Practice Address - Fax:305-246-5880
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-10
Last Update Date:2021-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY168071208000000X
FLME122911208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY012072258Medicaid
FL015562600Medicaid