Healthcare Provider Details

I. General information

NPI: 1891596375
Provider Name (Legal Business Name): MARC DARLENE MEZIDOR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/21/2025
Last Update Date: 06/29/2026
Certification Date: 04/28/2026
Deactivation Date: 04/28/2026
Reactivation Date: 06/29/2026

III. Provider practice location address

1069 NE 157TH TER
NORTH MIAMI BEACH FL
33162-5335
US

IV. Provider business mailing address

6817 N SEELEY AVE
CHICAGO IL
60645-4918
US

V. Phone/Fax

Practice location:
  • Phone: 786-515-5812
  • Fax:
Mailing address:
  • Phone: 786-515-5812
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2577
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: