Healthcare Provider Details

I. General information

NPI: 1962492413
Provider Name (Legal Business Name): MARIO J MONTELEONE PAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/26/2005
Last Update Date: 03/28/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7932 W SAND LAKE RD SUITE 202
ORLANDO FL
32819-7263
US

IV. Provider business mailing address

PO BOX 690609
ORLANDO FL
32869-0609
US

V. Phone/Fax

Practice location:
  • Phone: 407-846-7546
  • Fax: 321-206-5419
Mailing address:
  • Phone: 407-846-7546
  • Fax: 321-206-5419

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9100983
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: