Provider Demographics
NPI:1255325361
Name:MAZARIEGOS, MIGUEL ANGEL (MD)
Entity Type:Individual
Prefix:
First Name:MIGUEL
Middle Name:ANGEL
Last Name:MAZARIEGOS
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 1:1150 BELL SHOALS RD
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33511-9001
Mailing Address - Country:US
Mailing Address - Phone:813-681-6064
Mailing Address - Fax:813-653-4132
Practice Address - Street 1:1150 BELL SHOALS RD
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-9001
Practice Address - Country:US
Practice Address - Phone:813-681-6064
Practice Address - Fax:813-653-4132
Is Sole Proprietor?:No
Enumeration Date:2005-09-02
Last Update Date:2021-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0069553208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL378959400Medicaid
FL378959400Medicaid