Provider Demographics
NPI:1134158884
Name:JACOMINO, MARIO (MD, MPH)
Entity type:Individual
Prefix:
First Name:MARIO
Middle Name:
Last Name:JACOMINO
Suffix:
Gender:M
Credentials:MD, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:182 CITRUS TRAIL CIR
Mailing Address - Street 2:
Mailing Address - City:BOYNTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33436-1829
Mailing Address - Country:US
Mailing Address - Phone:561-733-2846
Mailing Address - Fax:
Practice Address - Street 1:777 GLADES RD # BC-71
Practice Address - Street 2:
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33431-6496
Practice Address - Country:US
Practice Address - Phone:561-297-0723
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-02
Last Update Date:2022-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME00637602083P0901X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2083P0901XAllopathic & Osteopathic PhysiciansPreventive MedicinePublic Health & General Preventive Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL3791033-00Medicaid
FLG10691Medicare UPIN