Healthcare Provider Details

I. General information

NPI: 1184961898
Provider Name (Legal Business Name): MARIA M MENA MD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/15/2013
Last Update Date: 01/15/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 E NORTH BLVD SUITE 101
LEESBURG FL
34748-5262
US

IV. Provider business mailing address

401 E NORTH BLVD SUITE 101
LEESBURG FL
34748-5262
US

V. Phone/Fax

Practice location:
  • Phone: 352-435-7772
  • Fax:
Mailing address:
  • Phone: 352-435-7772
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. MARIA MAGDALENA MENA
Title or Position: OWNER
Credential: MD
Phone: 352-435-7772