Provider Demographics
NPI:1124064456
Name:RENE AB CAPULONG MDPA
Entity type:Organization
Organization Name:RENE AB CAPULONG MDPA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT SURGEON
Authorized Official - Prefix:
Authorized Official - First Name:RENE
Authorized Official - Middle Name:AB
Authorized Official - Last Name:CAPULONG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:386-736-7600
Mailing Address - Street 1:PO BOX 310
Mailing Address - Street 2:
Mailing Address - City:DE LEON SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32130-0310
Mailing Address - Country:US
Mailing Address - Phone:386-736-7600
Mailing Address - Fax:386-738-4649
Practice Address - Street 1:2511 JUNIOR ST
Practice Address - Street 2:
Practice Address - City:ORANGE CITY
Practice Address - State:FL
Practice Address - Zip Code:32763-8000
Practice Address - Country:US
Practice Address - Phone:386-736-7600
Practice Address - Fax:386-738-4649
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-22
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME17644208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL053163400Medicaid
D59834Medicare UPIN
91841Medicare ID - Type Unspecified