Basic Information
| Provider Information | |||||||||
| NPI: | 1265752000 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MEZQUITA | ||||||||
| FirstName: | MADELYN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 121 S ORANGE AVE STE 940 | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328013234 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3213326947 | ||||||||
| FaxNumber: | 4072864515 | ||||||||
| Practice Location | |||||||||
| Address1: | 3162 S. CONWAY RD | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 32812 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4072760056 | ||||||||
| FaxNumber: | 4072370355 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/03/2010 | ||||||||
| LastUpdateDate: | 02/28/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 02/28/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | 53509-020 | WI | N | Allopathic & Osteopathic Physicians | General Practice | 208D00000X | ACN 344 | FL | Y | Allopathic & Osteopathic Physicians | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 003372100 | 05 | FL | MEDICAID |