Healthcare Provider Details

I. General information

NPI: 1457310724
Provider Name (Legal Business Name): MARIO EMILIO PELLETIER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/23/2006
Last Update Date: 08/18/2026
Certification Date: 08/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2000 CYPRESS CROSSING DR STE A
ORLANDO FL
32837-8600
US

IV. Provider business mailing address

2000 CYPRESS CROSSING DR STE A
ORLANDO FL
32837-8600
US

V. Phone/Fax

Practice location:
  • Phone: 407-515-1507
  • Fax: 407-515-8555
Mailing address:
  • Phone: 407-515-1507
  • Fax: 407-515-8555

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number42560
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberME159611
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: