Provider Demographics
NPI:1184961898
Name:MARIA M MENA MD
Entity type:Organization
Organization Name:MARIA M MENA MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARIA
Authorized Official - Middle Name:MAGDALENA
Authorized Official - Last Name:MENA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:352-435-7772
Mailing Address - Street 1:401 E NORTH BLVD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:LEESBURG
Mailing Address - State:FL
Mailing Address - Zip Code:34748-5262
Mailing Address - Country:US
Mailing Address - Phone:352-435-7772
Mailing Address - Fax:
Practice Address - Street 1:401 E NORTH BLVD
Practice Address - Street 2:SUITE 101
Practice Address - City:LEESBURG
Practice Address - State:FL
Practice Address - Zip Code:34748-5262
Practice Address - Country:US
Practice Address - Phone:352-435-7772
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-15
Last Update Date:2013-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL007161200Medicaid