Healthcare Provider Details

I. General information

NPI: 1194776989
Provider Name (Legal Business Name): MARY MAGNO MOURACADE M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/15/2006
Last Update Date: 07/07/2026
Certification Date: 07/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14560 HOPE CENTER LOOP
FORT MYERS FL
33912-4711
US

IV. Provider business mailing address

14560 HOPE CENTER LOOP
FORT MYERS FL
33912-4711
US

V. Phone/Fax

Practice location:
  • Phone: 239-939-0999
  • Fax: 239-939-1070
Mailing address:
  • Phone: 239-939-0999
  • Fax: 239-939-1070

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License NumberME65887
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberME65887
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code207RA0401X
TaxonomyAddiction Medicine (Internal Medicine) Physician
License NumberME65887
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: