Provider Demographics
NPI:1619167038
Name:MENGUITO, ROBERTO GAUDDAH (MD)
Entity type:Individual
Prefix:DR
First Name:ROBERTO
Middle Name:GAUDDAH
Last Name:MENGUITO
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 1:150 RIDGEWAY DR
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:WV
Mailing Address - Zip Code:26330-1175
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:947 TOWN CENTER DR
Practice Address - Street 2:
Practice Address - City:ORANGE CITY
Practice Address - State:FL
Practice Address - Zip Code:32763-8361
Practice Address - Country:US
Practice Address - Phone:386-366-5530
Practice Address - Fax:855-936-1288
Is Sole Proprietor?:No
Enumeration Date:2007-08-01
Last Update Date:2025-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVAS22959041564390200000X
174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program