MEDICARE: MARIO ALBERTO IRAHETA ABREGO MD

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	208000000X	Pediatrics Physician	ME147054	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1689954760
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARIO ALBERTO IRAHETA ABREGO MD

Provider Business Mailing Address
First Line	:	900 S PINE ISLAND RD STE 800
Second Line	:
City	:	PLANTATION
State	:	FL
Zip	:	33324-3923
Country	:	US
Telephone Number	:	904-354-6868
Fax Number	:	904-358-3067

Provider Business Practice Location Address
First Line	:	1714 N MAIN ST
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32206-4404
Country	:	US
Telephone Number	:	904-354-6868
Fax Number	:	904-358-3067

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

Provider Enumeration Date	:	08/22/2011
Last Update Date	:	09/08/2021

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