Provider Demographics
NPI:1669438214
Name:MAFFEZZOLI, RICHARD DIEGO (MD)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:DIEGO
Last Name:MAFFEZZOLI
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 1:3434 HANCOCK BRIDGE PKWY
Mailing Address - Street 2:STE. 301
Mailing Address - City:NORTH FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33903-7094
Mailing Address - Country:US
Mailing Address - Phone:877-856-3774
Mailing Address - Fax:239-599-2625
Practice Address - Street 1:1735 SW HEALTH PKWY
Practice Address - Street 2:STE. 201
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34109-0421
Practice Address - Country:US
Practice Address - Phone:239-249-7800
Practice Address - Fax:239-249-7803
Is Sole Proprietor?:No
Enumeration Date:2006-04-24
Last Update Date:2014-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD07132207R00000X
FLME117859207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD025571800Medicaid
MD5593Medicare ID - Type Unspecified
MD025571800Medicaid