Healthcare Provider Details

I. General information

NPI: 1265752000
Provider Name (Legal Business Name): MADELYN MEZQUITA M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/03/2010
Last Update Date: 02/28/2020
Certification Date: 02/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3162 S. CONWAY RD
ORLANDO FL
32812
US

IV. Provider business mailing address

121 S ORANGE AVE STE 940
ORLANDO FL
32801-3234
US

V. Phone/Fax

Practice location:
  • Phone: 407-276-0056
  • Fax: 407-237-0355
Mailing address:
  • Phone: 321-332-6947
  • Fax: 407-286-4515

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number53509-020
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberACN 344
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: