Basic Information
| Provider Information | |||||||||
| NPI: | 1992879944 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MAYORGA | ||||||||
| FirstName: | RENE | ||||||||
| MiddleName: | N | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 14261 SW 120TH ST STE 110 | ||||||||
| Address2: | |||||||||
| City: | MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331867273 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3053781302 | ||||||||
| FaxNumber: | 3053781311 | ||||||||
| Practice Location | |||||||||
| Address1: | 14261 SW 120TH ST STE 110 | ||||||||
| Address2: | |||||||||
| City: | MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331867273 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3053781302 | ||||||||
| FaxNumber: | 3053781311 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/20/2006 | ||||||||
| LastUpdateDate: | 10/25/2010 | ||||||||
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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 | 207Q00000X | ME 54068 | FL | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 08688 | 01 | FL | BLUE CROSS BLUE SHIEL | OTHER | 2132789 | 01 | AETNA | OTHER |