Healthcare Provider Details

I. General information

NPI: 1316992365
Provider Name (Legal Business Name): MARCO TEODORO BOLOGNA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/24/2006
Last Update Date: 07/19/2022
Certification Date: 07/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8950 N KENDALL DR STE 506W
MIAMI FL
33176-2127
US

IV. Provider business mailing address

PO BOX 198054
ATLANTA GA
30384-8054
US

V. Phone/Fax

Practice location:
  • Phone: 786-596-1230
  • Fax: 786-533-9297
Mailing address:
  • Phone: 786-594-6880
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License NumberME97766
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number25242
License Number StateAL
# 3
Primary TaxonomyY
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License NumberME97766
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: