Basic Information
| Provider Information | |||||||||
| NPI: | 1689954760 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | IRAHETA ABREGO | ||||||||
| FirstName: | MARIO | ||||||||
| MiddleName: | ALBERTO | ||||||||
| NamePrefix: | |||||||||
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| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | IRAHETA | ||||||||
| OtherFirstName: | MARIO | ||||||||
| OtherMiddleName: | A | ||||||||
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| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 900 S PINE ISLAND RD STE 800 | ||||||||
| Address2: | |||||||||
| City: | PLANTATION | ||||||||
| State: | FL | ||||||||
| PostalCode: | 333243923 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9043546868 | ||||||||
| FaxNumber: | 9043583067 | ||||||||
| Practice Location | |||||||||
| Address1: | 1714 N MAIN ST | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322064404 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9043546868 | ||||||||
| FaxNumber: | 9043583067 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/22/2011 | ||||||||
| LastUpdateDate: | 09/08/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/08/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | ME147054 | FL | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 108158500 | 05 | FL | MEDICAID |