Provider Demographics
NPI:1407012164
Name:JOHN, MARIO ANTONIO (MD)
Entity Type:Individual
Prefix:DR
First Name:MARIO
Middle Name:ANTONIO
Last Name:JOHN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:483 N SEMORAN BLVD
Mailing Address - Street 2:STE 210
Mailing Address - City:WINTER PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32792-3800
Mailing Address - Country:US
Mailing Address - Phone:407-500-3627
Mailing Address - Fax:407-930-4353
Practice Address - Street 1:3030 HARDEN BLVD
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33803-7952
Practice Address - Country:US
Practice Address - Phone:863-687-1250
Practice Address - Fax:863-687-1258
Is Sole Proprietor?:No
Enumeration Date:2008-08-01
Last Update Date:2022-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME118804207X00000X
VA390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLHW629ZMedicare Oscar/Certification