Basic Information
| Provider Information | |||||||||
| NPI: | 1134384464 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MARIANO S LACAYO MD PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 830653 | ||||||||
| Address2: | |||||||||
| City: | MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 332830653 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7862815358 | ||||||||
| FaxNumber: | 3052551669 | ||||||||
| Practice Location | |||||||||
| Address1: | 7821 CORAL WAY | ||||||||
| Address2: | STE 101 | ||||||||
| City: | MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331556542 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7862815358 | ||||||||
| FaxNumber: | 3052551669 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/25/2008 | ||||||||
| LastUpdateDate: | 01/14/2009 | ||||||||
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| AuthorizedOfficialLastName: | LACAYO | ||||||||
| AuthorizedOfficialFirstName: | MARIANO | ||||||||
| AuthorizedOfficialMiddleName: | S | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7862815358 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | ME89783 | FL | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 271309800 | 05 | FL | MEDICAID |