Provider Demographics
NPI:1851309298
Name:MARI C FIELDING MD PA
Entity Type:Organization
Organization Name:MARI C FIELDING MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARI
Authorized Official - Middle Name:CHARLENE
Authorized Official - Last Name:FIELDING
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:863-616-9017
Mailing Address - Street 1:PO BOX 425
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33803
Mailing Address - Country:US
Mailing Address - Phone:863-616-9017
Mailing Address - Fax:863-682-4677
Practice Address - Street 1:2720 NEVADA RD
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33803
Practice Address - Country:US
Practice Address - Phone:863-668-8215
Practice Address - Fax:863-682-4677
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-03
Last Update Date:2011-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0066256208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL263832101Medicaid
25369OtherBCBS
FLK0883OtherMEDICARE LEGACY PROVIDER#
FLK0883Medicare PIN
FLK0883OtherMEDICARE LEGACY PROVIDER#