Provider Demographics
NPI:1942295639
Name:MENDIZABAL, MARIO A (MD)
Entity Type:Individual
Prefix:MR
First Name:MARIO
Middle Name:A
Last Name:MENDIZABAL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:2320 N SUNSHINE PATH
Mailing Address - Street 2:
Mailing Address - City:CRYSTAL RIVER
Mailing Address - State:FL
Mailing Address - Zip Code:34428-5810
Mailing Address - Country:US
Mailing Address - Phone:352-795-5888
Mailing Address - Fax:352-795-6968
Practice Address - Street 1:921 N CITRUS AVE
Practice Address - Street 2:
Practice Address - City:CRYSTAL RIVER
Practice Address - State:FL
Practice Address - Zip Code:34428-3422
Practice Address - Country:US
Practice Address - Phone:352-436-4328
Practice Address - Fax:352-260-0960
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-19
Last Update Date:2019-08-22
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLME0027030207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL080122893Medicare PIN
FLE12163Medicare UPIN
FLQ0215Medicare PIN
FL78861XMedicare PIN