Provider Demographics
NPI:1174510341
Name:TANO, MARIO ENRIQUE (MD)
Entity Type:Individual
Prefix:DR
First Name:MARIO
Middle Name:ENRIQUE
Last Name:TANO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5955 PONCE DE LEON BLVD.
Mailing Address - Street 2:
Mailing Address - City:CORAL GABLES
Mailing Address - State:FL
Mailing Address - Zip Code:33146
Mailing Address - Country:US
Mailing Address - Phone:305-661-1515
Mailing Address - Fax:305-662-3723
Practice Address - Street 1:3800 JOHNSON ST STE J
Practice Address - Street 2:
Practice Address - City:HOLLYWOOD
Practice Address - State:FL
Practice Address - Zip Code:33021-6030
Practice Address - Country:US
Practice Address - Phone:954-967-9400
Practice Address - Fax:954-967-9551
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-04
Last Update Date:2022-02-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLME583522080P0206X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0206XAllopathic & Osteopathic PhysiciansPediatricsPediatric Gastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL064237100Medicaid
FL064237100Medicaid
FLE66536Medicare UPIN