Healthcare Provider Details

I. General information

NPI: 1457310724
Provider Name (Legal Business Name): MARIO EMILIO PELLETIER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/23/2006
Last Update Date: 11/28/2025
Certification Date: 11/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

920 N JOHN YOUNG PKWY
KISSIMMEE FL
34741-4914
US

IV. Provider business mailing address

425 W COLONIAL DR STE 303
ORLANDO FL
32804-6863
US

V. Phone/Fax

Practice location:
  • Phone: 407-956-1920
  • Fax: 833-450-5410
Mailing address:
  • Phone: 407-956-1920
  • Fax: 689-304-0303

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number42560
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberME159611
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: