Provider Demographics
NPI:1629017652
Name:MENACKER, MOREY J (DO)
Entity Type:Individual
Prefix:DR
First Name:MOREY
Middle Name:J
Last Name:MENACKER
Suffix:
Gender:M
Credentials:DO
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 616788
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32861-6788
Mailing Address - Country:US
Mailing Address - Phone:407-533-6835
Mailing Address - Fax:407-770-0661
Practice Address - Street 1:7649 W COLONIAL DR STE 115
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32818-7423
Practice Address - Country:US
Practice Address - Phone:407-552-2080
Practice Address - Fax:339-630-1158
Is Sole Proprietor?:No
Enumeration Date:2006-06-05
Last Update Date:2021-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMB43067207R00000X
FLOS16624207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME457147Medicare ID - Type Unspecified
C53864Medicare UPIN