Provider Demographics
NPI:1669804720
Name:THELIARD, MARIO (MD)
Entity type:Individual
Prefix:DR
First Name:MARIO
Middle Name:
Last Name:THELIARD
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 1:2330 S CONGRESS AVE
Mailing Address - Street 2:
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33406-7608
Mailing Address - Country:US
Mailing Address - Phone:561-432-5849
Mailing Address - Fax:
Practice Address - Street 1:2330 S CONGRESS AVE
Practice Address - Street 2:
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33406-7608
Practice Address - Country:US
Practice Address - Phone:561-432-5849
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-31
Last Update Date:2024-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR020982208D00000X
FLME140780208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLOS240OtherMEDICARE
FL010726500Medicaid
FLMARIO71Medicare Oscar/Certification
FL1669804720Medicare Oscar/Certification
FL1669804720Medicare NSC
FL1669804720Medicaid
FL1669804720Medicare UPIN
FLMARIO71Medicare UPIN
FL1669804720Medicare PIN