Basic Information
Provider Information | |||||||||
NPI: | 1033205091 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MESIDOR | ||||||||
FirstName: | DOMINIQUE | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2010 59TH ST W | ||||||||
Address2: | SUITE 2200 | ||||||||
City: | BRADENTON | ||||||||
State: | FL | ||||||||
PostalCode: | 342094616 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9417945621 | ||||||||
FaxNumber: | 9417611532 | ||||||||
Practice Location | |||||||||
Address1: | 2010 59TH ST W | ||||||||
Address2: | SUITE 2200 | ||||||||
City: | BRADENTON | ||||||||
State: | FL | ||||||||
PostalCode: | 342094616 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9417945621 | ||||||||
FaxNumber: | 9417611532 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/05/2006 | ||||||||
LastUpdateDate: | 11/01/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2086S0127X | ME0086398 | FL | N |   | Allopathic & Osteopathic Physicians | Surgery | Trauma Surgery | 2086S0102X | 044539 | GA | Y |   | Allopathic & Osteopathic Physicians | Surgery | Surgical Critical Care |
ID Information
ID | Type | State | Issuer | Description | U1254X | 01 | FL | MEDICARE | OTHER | 267667200 | 05 | FL |   | MEDICAID |