Provider Demographics
NPI:1356322572
Name:MEDARY, IRENE B (MD)
Entity Type:Individual
Prefix:
First Name:IRENE
Middle Name:B
Last Name:MEDARY
Suffix:
Gender:F
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:PO BOX 692409
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32869-2409
Mailing Address - Country:US
Mailing Address - Phone:407-355-0575
Mailing Address - Fax:407-355-0576
Practice Address - Street 1:7340 STONEROCK CIR
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32819
Practice Address - Country:US
Practice Address - Phone:407-355-0575
Practice Address - Fax:407-355-0576
Is Sole Proprietor?:No
Enumeration Date:2005-11-07
Last Update Date:2020-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME589002086S0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0102XAllopathic & Osteopathic PhysiciansSurgerySurgical Critical Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL2153616OtherAETNA
FLE97625Medicare UPIN
E97625Medicare UPIN
FL2153616OtherAETNA
12840AMedicare PIN
12840VMedicare PIN