Basic Information
Provider Information
NPI: 1942773569
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: CECILIO
FirstName: MARIO
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 16484 SW 139TH CT
Address2:  
City: MIAMI
State: FL
PostalCode: 331772023
CountryCode: US
TelephoneNumber:  
FaxNumber:  
Practice Location
Address1: 717 PONCE DE LEON BLVD STE 219
Address2:  
City: CORAL GABLES
State: FL
PostalCode: 331342048
CountryCode: US
TelephoneNumber: 3056193202
FaxNumber:  
Other Information
ProviderEnumerationDate: 01/07/2019
LastUpdateDate: 01/07/2019
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
106S00000X  Y193400000X SINGLE SPECIALTY GROUP   

No ID Information.


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