Provider Demographics
NPI:1619925484
Name:MABANTA, SHEILAINE R (MD)
Entity Type:Individual
Prefix:DR
First Name:SHEILAINE
Middle Name:R
Last Name:MABANTA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MISS
Other - First Name:SHEILAINE
Other - Middle Name:
Other - Last Name:RODRIGO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2501 N ORANGE AVE STE 182
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32804-4675
Mailing Address - Country:US
Mailing Address - Phone:407-303-2030
Mailing Address - Fax:
Practice Address - Street 1:4200 SUN N LAKE BLVD
Practice Address - Street 2:
Practice Address - City:SEBRING
Practice Address - State:FL
Practice Address - Zip Code:33872-1986
Practice Address - Country:US
Practice Address - Phone:407-303-2030
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2021-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME74201174400000X, 2085R0001X
MNPENDING2085R0001X
TXP69992085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX328624701Medicaid
FL259085900Medicaid
TX295100YS65OtherMEDICARE ID
FLH12849Medicare UPIN
TX328624701Medicaid