Provider Demographics
NPI:1831489772
Name:CHANLATTE-ITHIER, MARINO AMAURY (MD)
Entity Type:Individual
Prefix:
First Name:MARINO
Middle Name:AMAURY
Last Name:CHANLATTE-ITHIER
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 1:483 N SEMORAN BLVD
Mailing Address - Street 2:STE #103
Mailing Address - City:WINTER PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32792-3800
Mailing Address - Country:US
Mailing Address - Phone:407-680-2273
Mailing Address - Fax:321-274-0224
Practice Address - Street 1:483 N SEMORAN BLVD
Practice Address - Street 2:STE #103
Practice Address - City:WINTER PARK
Practice Address - State:FL
Practice Address - Zip Code:32792-3800
Practice Address - Country:US
Practice Address - Phone:407-680-2273
Practice Address - Fax:321-274-0224
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-12
Last Update Date:2016-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR12726207P00000X
FLME117097207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL009431000Medicaid
FL009431000Medicaid