Healthcare Provider Details

I. General information

NPI: 1770720138
Provider Name (Legal Business Name): MEDERO MEDICAL OF ORANGE SOUTH, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/07/2009
Last Update Date: 01/07/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1109 SW 10TH ST
OCALA FL
34471-0325
US

IV. Provider business mailing address

9500 SATELLITE BLVD STE 100
ORLANDO FL
32837-8464
US

V. Phone/Fax

Practice location:
  • Phone: 352-629-3433
  • Fax: 352-629-6796
Mailing address:
  • Phone: 352-629-3433
  • Fax: 352-629-6796

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2083X0100X
TaxonomyOccupational Medicine Physician
License Number12790
License Number StateFL

VIII. Authorized Official

Name: MR. LARRY MAYFIELD
Title or Position: ADMINISTRATOR
Credential:
Phone: 352-629-3433