Healthcare Provider Details

I. General information

NPI: 1992879944
Provider Name (Legal Business Name): RENE N MAYORGA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/20/2006
Last Update Date: 10/25/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14261 SW 120TH ST STE 110
MIAMI FL
33186-7273
US

IV. Provider business mailing address

14261 SW 120TH ST STE 110
MIAMI FL
33186-7273
US

V. Phone/Fax

Practice location:
  • Phone: 305-378-1302
  • Fax: 305-378-1311
Mailing address:
  • Phone: 305-378-1302
  • Fax: 305-378-1311

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberME 54068
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: