Provider Demographics
NPI:1003255191
Name:CO, MARY ANTONETTE MAGLALANG (MD)
Entity type:Individual
Prefix:
First Name:MARY ANTONETTE
Middle Name:MAGLALANG
Last Name:CO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:900 S PINE ISLAND RD STE 800
Mailing Address - Street 2:
Mailing Address - City:PLANTATION
Mailing Address - State:FL
Mailing Address - Zip Code:33324-3923
Mailing Address - Country:US
Mailing Address - Phone:305-940-6016
Mailing Address - Fax:305-940-6167
Practice Address - Street 1:1610 NE MIAMI GARDENS DR
Practice Address - Street 2:
Practice Address - City:N MIAMI BEACH
Practice Address - State:FL
Practice Address - Zip Code:33179
Practice Address - Country:US
Practice Address - Phone:305-940-6016
Practice Address - Fax:305-940-6167
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-21
Last Update Date:2020-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
FLME134120208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL023344600Medicaid