Healthcare Provider Details

I. General information

NPI: 1609869833
Provider Name (Legal Business Name): GABOR MENCZELESZ MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/23/2005
Last Update Date: 03/21/2024
Certification Date: 03/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3574 US HIGHWAY 1 S STE 102
SAINT AUGUSTINE FL
32086-6467
US

IV. Provider business mailing address

4620 PEELE ST
ELKTON FL
32033-4015
US

V. Phone/Fax

Practice location:
  • Phone: 904-217-7161
  • Fax: 904-217-4075
Mailing address:
  • Phone: 904-302-1558
  • Fax: 904-562-3343

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberME122201
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberME122201
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number210461
License Number StateNY
# 4
Primary TaxonomyY
Taxonomy Code207RA0401X
TaxonomyAddiction Medicine (Internal Medicine) Physician
License NumberME122201
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: