Provider Demographics
NPI:1659334670
Name:RENE N MAYORGA M D P A
Entity Type:Organization
Organization Name:RENE N MAYORGA M D P A
Other - Org Name:COUNTRY WALK FAMILY MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RENE
Authorized Official - Middle Name:N
Authorized Official - Last Name:MAYORGA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:305-378-1302
Mailing Address - Street 1:14261 SW 120TH ST
Mailing Address - Street 2:SUITE 110
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33186-7270
Mailing Address - Country:US
Mailing Address - Phone:305-378-1302
Mailing Address - Fax:305-378-1311
Practice Address - Street 1:14261 SW 120TH ST
Practice Address - Street 2:SUITE 110
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33186-7270
Practice Address - Country:US
Practice Address - Phone:305-378-1302
Practice Address - Fax:305-378-1311
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-10
Last Update Date:2011-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME54068207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL14292OtherVISTA
FL003349OtherNEIGHBORHOOD HEALTH PART
FL2132789OtherAETNA
FLF00138402601OtherNEIGBORHOOD HEALTH
FL061439400Medicaid
FL08688OtherBLUE CROSS BLUE SHIELD
FL0170072OtherUNITED
FL101635OtherAVMED
FL=========OtherTRICARE REG 3 & 4
FL061439400Medicaid
FL=========OtherGHI
FL=========OtherHUMANA
FL=========OtherTRICARE REG 3 & 4
FL08688OtherBLUE CROSS BLUE SHIELD
FLE31277Medicare UPIN