Healthcare Provider Details

I. General information

NPI: 1730111527
Provider Name (Legal Business Name): IVAN DARIO MAYA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/06/2006
Last Update Date: 05/06/2024
Certification Date: 05/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

766 N SUN DR SUITE 3030
LAKE MARY FL
32746-2552
US

IV. Provider business mailing address

807 S ORLANDO AVE SUITE C
WINTER PARK FL
32789-4870
US

V. Phone/Fax

Practice location:
  • Phone: 407-444-2800
  • Fax:
Mailing address:
  • Phone: 407-515-2211
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License NumberME107626
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: