Healthcare Provider Details

I. General information

NPI: 1174510341
Provider Name (Legal Business Name): MARIO ENRIQUE TANO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/04/2005
Last Update Date: 02/08/2022
Certification Date: 02/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3800 JOHNSON ST STE J
HOLLYWOOD FL
33021-6030
US

IV. Provider business mailing address

5955 PONCE DE LEON BLVD.
CORAL GABLES FL
33146
US

V. Phone/Fax

Practice location:
  • Phone: 954-967-9400
  • Fax: 954-967-9551
Mailing address:
  • Phone: 305-661-1515
  • Fax: 305-662-3723

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0206X
TaxonomyPediatric Gastroenterology Physician
License NumberME58352
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: