Healthcare Provider Details

I. General information

NPI: 1265471536
Provider Name (Legal Business Name): ROBERT A. MEVORACH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/05/2006
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5153 N 9TH AVE
PENSACOLA FL
32504-8785
US

IV. Provider business mailing address

25 CROSSROADS DR SUITE 306
OWINGS MILLS MD
21117-5421
US

V. Phone/Fax

Practice location:
  • Phone: 850-505-4700
  • Fax:
Mailing address:
  • Phone: 443-738-2872
  • Fax: 443-738-2713

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number166646
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code2088P0231X
TaxonomyPediatric Urology Physician
License Number166646
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code2088P0231X
TaxonomyPediatric Urology Physician
License NumberME128200
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: