Provider Demographics
NPI:1265752000
Name:MEZQUITA, MADELYN (MD)
Entity type:Individual
Prefix:DR
First Name:MADELYN
Middle Name:
Last Name:MEZQUITA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:121 S ORANGE AVE STE 940
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32801-3234
Mailing Address - Country:US
Mailing Address - Phone:321-332-6947
Mailing Address - Fax:407-286-4515
Practice Address - Street 1:3162 S. CONWAY RD
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32812
Practice Address - Country:US
Practice Address - Phone:407-276-0056
Practice Address - Fax:407-237-0355
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-03
Last Update Date:2020-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI53509-020208D00000X
FLACN 344208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL003372100Medicaid
FL003372100Medicaid