Provider Demographics
NPI:1619913191
Name:MENOR, EDWIN S (MD)
Entity Type:Individual
Prefix:
First Name:EDWIN
Middle Name:S
Last Name:MENOR
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 1:1020 LAKE SUMTER LNDG
Mailing Address - Street 2:
Mailing Address - City:THE VILLAGES
Mailing Address - State:FL
Mailing Address - Zip Code:32162-2699
Mailing Address - Country:US
Mailing Address - Phone:352-674-8700
Mailing Address - Fax:352-674-8714
Practice Address - Street 1:1400 N US HIGHWAY 441
Practice Address - Street 2:SUITE 810
Practice Address - City:THE VILLAGES
Practice Address - State:FL
Practice Address - Zip Code:32159-8975
Practice Address - Country:US
Practice Address - Phone:352-674-8700
Practice Address - Fax:352-674-8714
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-21
Last Update Date:2015-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH13681208600000X
MA231399208600000X
FLME88439208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL270045000Medicaid
FLH93498Medicare UPIN
FL270045000Medicaid