Provider Demographics
NPI:1962492413
Name:MONTELEONE, MARIO J (PAC)
Entity Type:Individual
Prefix:MR
First Name:MARIO
Middle Name:J
Last Name:MONTELEONE
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 690609
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32869-0609
Mailing Address - Country:US
Mailing Address - Phone:407-846-7546
Mailing Address - Fax:321-206-5419
Practice Address - Street 1:7932 W SAND LAKE RD
Practice Address - Street 2:SUITE 202
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32819-7263
Practice Address - Country:US
Practice Address - Phone:407-846-7546
Practice Address - Fax:321-206-5419
Is Sole Proprietor?:No
Enumeration Date:2005-10-26
Last Update Date:2018-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9100983363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL008106200Medicaid
S84087Medicare UPIN
FL008106200Medicaid