MEDICARE: MARISSA ESTIVA-MAGSINO MDPA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	ME72766	FL

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	K7670	OTHER	FL	MEDICARE GROUP NUMBER

General Provider Information

NPI Number	:	1366413544
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MARISSA ESTIVA-MAGSINO MDPA

Provider Business Mailing Address
First Line	:	PO BOX 2965
Second Line	:
City	:	WINDERMERE
State	:	FL
Zip	:	34786-2965
Country	:	US
Telephone Number	:	407-292-6778
Fax Number	:

Provider Business Practice Location Address
First Line	:	1507 S HIAWASSEE RD
Second Line	:	SUITE 115
City	:	ORLANDO
State	:	FL
Zip	:	32835-5706
Country	:	US
Telephone Number	:	407-292-6778
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. MARISSA ESTIVA MAGSINO
Credential	:	MD
Telephone Number	:	407-292-6778

Provider Enumeration Date	:	01/27/2006
Last Update Date	:	11/09/2007

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