Healthcare Provider Details

I. General information

NPI: 1275799637
Provider Name (Legal Business Name): MARY THERESA ELENGICAL D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/05/2008
Last Update Date: 01/06/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 WATERMAN WAY DEPARTMENT OF ANESTHESIA
TAVARES FL
32778-5266
US

IV. Provider business mailing address

PO BOX 3130
OCALA FL
34478-3130
US

V. Phone/Fax

Practice location:
  • Phone: 352-253-3333
  • Fax:
Mailing address:
  • Phone: 352-867-8311
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberOS11134
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number125052315
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: