Provider Demographics
NPI:1477650695
Name:MARDY, GISELE VICTOR (MD)
Entity type:Individual
Prefix:DR
First Name:GISELE
Middle Name:VICTOR
Last Name:MARDY
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 1:9299W 152TH ST #207
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33157
Mailing Address - Country:US
Mailing Address - Phone:305-253-6654
Mailing Address - Fax:305-235-3501
Practice Address - Street 1:9299 SW 152TH ST
Practice Address - Street 2:#207
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33157
Practice Address - Country:US
Practice Address - Phone:305-253-6654
Practice Address - Fax:305-235-3501
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2012-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0070216208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL250371900Medicaid
F79593Medicare UPIN
08606Medicare ID - Type Unspecified