Provider Demographics
NPI:1275680977
Name:FERNANDEZ-GRELA, MARIO J (MD)
Entity Type:Individual
Prefix:DR
First Name:MARIO
Middle Name:J
Last Name:FERNANDEZ-GRELA
Suffix:
Gender:M
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:PO BOX 3130
Mailing Address - Street 2:
Mailing Address - City:OCALA
Mailing Address - State:FL
Mailing Address - Zip Code:34478-3130
Mailing Address - Country:US
Mailing Address - Phone:352-867-8311
Mailing Address - Fax:352-622-5771
Practice Address - Street 1:700 DOCTORS CT
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:FL
Practice Address - Zip Code:34748-7314
Practice Address - Country:US
Practice Address - Phone:352-787-9838
Practice Address - Fax:352-787-8705
Is Sole Proprietor?:No
Enumeration Date:2007-01-04
Last Update Date:2015-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME94319207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL43176OtherBCBS FL & HEALTH OPTIONS
FL274916500Medicaid
FLU7208PMedicare PIN
FL274916500Medicaid
FLU7208XMedicare PIN
FLU7208QMedicare PIN
FLI51481Medicare UPIN
FLU7208WMedicare PIN
FLU7208SMedicare PIN
FLU7208PMedicare PIN