Basic Information
| Provider Information | |||||||||
| NPI: | 1679971881 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MAYORAL | ||||||||
| FirstName: | MARIELI | ||||||||
| MiddleName: | MILAGROS | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MAYORAL-HERNANDEZ | ||||||||
| OtherFirstName: | MARIELI | ||||||||
| OtherMiddleName: | MILAGROS | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 69 | ||||||||
| Address2: | |||||||||
| City: | JUPITER | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334680069 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5614066062 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1502 VILLAGE OAK LN | ||||||||
| Address2: | |||||||||
| City: | KISSIMMEE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 347466592 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4075203588 | ||||||||
| FaxNumber: | 4079786756 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/22/2014 | ||||||||
| LastUpdateDate: | 02/12/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | 18886 | PR | N | Allopathic & Osteopathic Physicians | General Practice | 208D00000X | ACN1034 | FL | Y | Allopathic & Osteopathic Physicians | General Practice |
ID Information
| ID | Type | State | Issuer | Description | ACN1034 | 01 | FL | STATE OF FLORIDA | OTHER | FM4992663 | 01 | FL | DEA | OTHER |