Provider Demographics
NPI:1346210333
Name:MONAHAN, MARYELLEN O (M D)
Entity Type:Individual
Prefix:
First Name:MARYELLEN
Middle Name:O
Last Name:MONAHAN
Suffix:
Gender:F
Credentials:M D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:919 SE CENTRAL PKWY
Mailing Address - Street 2:
Mailing Address - City:STUART
Mailing Address - State:FL
Mailing Address - Zip Code:34994-3904
Mailing Address - Country:US
Mailing Address - Phone:772-220-1391
Mailing Address - Fax:772-220-4087
Practice Address - Street 1:300 SE HOSPITAL AVE
Practice Address - Street 2:
Practice Address - City:STUART
Practice Address - State:FL
Practice Address - Zip Code:34994-2338
Practice Address - Country:US
Practice Address - Phone:772-220-1391
Practice Address - Fax:772-220-4087
Is Sole Proprietor?:No
Enumeration Date:2006-01-24
Last Update Date:2010-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME637122085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL256833100Medicaid
C31861Medicare UPIN
44883ZMedicare PIN
44883ZMedicare ID - Type Unspecified