MEDICARE: JOHN MAURIELLO M.D.

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	202K00000X	Phlebology Physician	95-00402	NC

General Provider Information

NPI Number	:	1457324766
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOHN MAURIELLO M.D.

Provider Business Mailing Address
First Line	:	4106 W LAKE MARY BLVD
Second Line	:	SUITE 324
City	:	LAKE MARY
State	:	FL
Zip	:	32746-3315
Country	:	US
Telephone Number	:	407-892-8484
Fax Number	:	407-892-8485

Provider Business Practice Location Address
First Line	:	4106 W LAKE MARY BLVD
Second Line	:	SUITE 324
City	:	LAKE MARY
State	:	FL
Zip	:	32746-3315
Country	:	US
Telephone Number	:	407-892-8484
Fax Number	:	407-892-8485

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/08/2006
Last Update Date	:	03/09/2008

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