Basic Information
| Provider Information | |||||||||
| NPI: | 1659334670 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | RENE N MAYORGA M D P A | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | COUNTRY WALK FAMILY MEDICINE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 14261 SW 120TH ST | ||||||||
| Address2: | SUITE 110 | ||||||||
| City: | MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331867270 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3053781302 | ||||||||
| FaxNumber: | 3053781311 | ||||||||
| Practice Location | |||||||||
| Address1: | 14261 SW 120TH ST | ||||||||
| Address2: | SUITE 110 | ||||||||
| City: | MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331867270 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3053781302 | ||||||||
| FaxNumber: | 3053781311 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/10/2006 | ||||||||
| LastUpdateDate: | 11/22/2011 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MAYORGA | ||||||||
| AuthorizedOfficialFirstName: | RENE | ||||||||
| AuthorizedOfficialMiddleName: | N | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3053781302 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | ME54068 | FL | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 14292 | 01 | FL | VISTA | OTHER | 003349 | 01 | FL | NEIGHBORHOOD HEALTH PART | OTHER | 2132789 | 01 | FL | AETNA | OTHER | F00138402601 | 01 | FL | NEIGBORHOOD HEALTH | OTHER | 061439400 | 05 | FL | MEDICAID | 08688 | 01 | FL | BLUE CROSS BLUE SHIELD | OTHER | 0170072 | 01 | FL | UNITED | OTHER | 101635 | 01 | FL | AVMED | OTHER |