Provider Demographics
NPI:1780684399
Name:MADONNA, DINO (MD)
Entity Type:Individual
Prefix:
First Name:DINO
Middle Name:
Last Name:MADONNA
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 1:601 E DIXIE AVE
Mailing Address - Street 2:MEDICAL PLAZA 901
Mailing Address - City:LEESBURG
Mailing Address - State:FL
Mailing Address - Zip Code:34748-5953
Mailing Address - Country:US
Mailing Address - Phone:352-728-2404
Mailing Address - Fax:352-787-7401
Practice Address - Street 1:601 E DIXIE AVE
Practice Address - Street 2:MEDICAL PLAZA 901
Practice Address - City:LEESBURG
Practice Address - State:FL
Practice Address - Zip Code:34748-5953
Practice Address - Country:US
Practice Address - Phone:352-728-2404
Practice Address - Fax:352-787-7401
Is Sole Proprietor?:No
Enumeration Date:2005-07-26
Last Update Date:2019-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME78248207YS0123X, 207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YS0123XAllopathic & Osteopathic PhysiciansOtolaryngologyFacial Plastic Surgery
No207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL256975200Medicaid
FLE2560ZMedicare ID - Type Unspecified