Basic Information
| Provider Information | |||||||||
| NPI: | 1104800226 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MERENDINO | ||||||||
| FirstName: | ANTONY | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DPM | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 3450 HULL RD | ||||||||
| Address2: | |||||||||
| City: | GAINESVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 326074144 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3522737394 | ||||||||
| FaxNumber: | 3522737395 | ||||||||
| Practice Location | |||||||||
| Address1: | 3450 HULL RD | ||||||||
| Address2: | |||||||||
| City: | GAINESVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 32607 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3522737394 | ||||||||
| FaxNumber: | 3522737395 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/01/2005 | ||||||||
| LastUpdateDate: | 11/06/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213E00000X | POD1035 | GA | N | Podiatric Medicine & Surgery Service Providers | Podiatrist | 213E00000X | DPM0000000651 | TN | N | Podiatric Medicine & Surgery Service Providers | Podiatrist | 213E00000X | PO2511 | FL | N | Podiatric Medicine & Surgery Service Providers | Podiatrist | 213E00000X | PO4108 | FL | Y | 193200000X MULTI-SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist |
ID Information
| ID | Type | State | Issuer | Description | 390291900 | 05 | FL | MEDICAID |