Healthcare Provider Details

I. General information

NPI: 1750329546
Provider Name (Legal Business Name): MARIO R REALE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/03/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4900 BAYOU BLVD SUITE 205
PENSACOLA FL
32503-2525
US

IV. Provider business mailing address

6731 AVENIDA DE GALVEZ
NAVARRE FL
32566-8919
US

V. Phone/Fax

Practice location:
  • Phone: 850-476-2387
  • Fax: 850-476-9707
Mailing address:
  • Phone: 850-936-4216
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License NumberME 80770
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: