Basic Information
| Provider Information | |||||||||
| NPI: | 1619913191 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MENOR | ||||||||
| FirstName: | EDWIN | ||||||||
| MiddleName: | S. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1020 LAKE SUMTER LNDG | ||||||||
| Address2: | |||||||||
| City: | THE VILLAGES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 321622699 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3526748700 | ||||||||
| FaxNumber: | 3526748714 | ||||||||
| Practice Location | |||||||||
| Address1: | 1400 N US HIGHWAY 441 | ||||||||
| Address2: | SUITE 810 | ||||||||
| City: | THE VILLAGES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 321598975 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3526748700 | ||||||||
| FaxNumber: | 3526748714 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/21/2006 | ||||||||
| LastUpdateDate: | 02/10/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 13681 | NH | N | Allopathic & Osteopathic Physicians | Surgery | 208600000X | 231399 | MA | N | Allopathic & Osteopathic Physicians | Surgery | 208600000X | ME88439 | FL | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 270045000 | 05 | FL | MEDICAID |