Provider Demographics
NPI:1073576146
Name:MEDICAL VENTURES OF AMERICA LLC
Entity type:Organization
Organization Name:MEDICAL VENTURES OF AMERICA LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:DELEGGE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:843-697-0400
Mailing Address - Street 1:16890 US HIGHWAY 441
Mailing Address - Street 2:
Mailing Address - City:MOUNT DORA
Mailing Address - State:FL
Mailing Address - Zip Code:32757-6705
Mailing Address - Country:US
Mailing Address - Phone:352-250-5546
Mailing Address - Fax:
Practice Address - Street 1:16890 US HIGHWAY 441
Practice Address - Street 2:
Practice Address - City:MOUNT DORA
Practice Address - State:FL
Practice Address - Zip Code:32757-6705
Practice Address - Country:US
Practice Address - Phone:352-250-5546
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-10
Last Update Date:2025-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes173000000XOther Service ProvidersLegal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL10D1004910OtherMEDICARE CLIA #
FL34537OtherBLUE GRP PROV #
FLB902BOtherBLUE SHIELD FACILITY #
FL266435600Medicaid
FL34537OtherBLUE GRP PROV #
FL34537Medicare ID - Type UnspecifiedMEDICARE GROUP PROV #