Provider Demographics
NPI:1730111527
Name:MAYA, IVAN DARIO (MD)
Entity Type:Individual
Prefix:
First Name:IVAN
Middle Name:DARIO
Last Name:MAYA
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 1:807 S ORLANDO AVE
Mailing Address - Street 2:SUITE C
Mailing Address - City:WINTER PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32789-4870
Mailing Address - Country:US
Mailing Address - Phone:407-515-2211
Mailing Address - Fax:
Practice Address - Street 1:766 N SUN DR
Practice Address - Street 2:SUITE 3030
Practice Address - City:LAKE MARY
Practice Address - State:FL
Practice Address - Zip Code:32746-2552
Practice Address - Country:US
Practice Address - Phone:407-444-2800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2010-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL19377207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALP00147264OtherRAILROAD MEDICARE
AL009950805Medicaid
AL009950815Medicaid
AL051521681OtherBLUE CROSS
AL051521682OtherBLUE CROSS
AL051521681Medicare ID - Type Unspecified