Provider Demographics
NPI:1750329546
Name:REALE, MARIO R (MD)
Entity Type:Individual
Prefix:
First Name:MARIO
Middle Name:R
Last Name:REALE
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 1:6731 AVENIDA DE GALVEZ
Mailing Address - Street 2:
Mailing Address - City:NAVARRE
Mailing Address - State:FL
Mailing Address - Zip Code:32566-8919
Mailing Address - Country:US
Mailing Address - Phone:850-936-4216
Mailing Address - Fax:
Practice Address - Street 1:4900 BAYOU BLVD
Practice Address - Street 2:SUITE 205
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32503-2525
Practice Address - Country:US
Practice Address - Phone:850-476-2387
Practice Address - Fax:850-476-9707
Is Sole Proprietor?:No
Enumeration Date:2006-06-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 807702080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine