Healthcare Provider Details

I. General information

NPI: 1174504690
Provider Name (Legal Business Name): FABIO MARIANO MEHRGUT M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/10/2005
Last Update Date: 08/18/2021
Certification Date: 05/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16255 SW 83RD LN
MIAMI FL
33193-5133
US

IV. Provider business mailing address

16255 SW 83RD LANE
MIAMI FL
33193
US

V. Phone/Fax

Practice location:
  • Phone: 786-479-7878
  • Fax: 305-246-5880
Mailing address:
  • Phone: 786-479-7878
  • Fax: 305-246-5880

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number168071
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME122911
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: