Provider Demographics
NPI:1154011641
Name:ROCHO MARGARA, FABIOLA (MATY1)
Entity type:Individual
Prefix:
First Name:FABIOLA
Middle Name:
Last Name:ROCHO MARGARA
Suffix:
Gender:F
Credentials:MATY1
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:451 SHREWSBURY RD
Mailing Address - Street 2:
Mailing Address - City:MARY ESTHER
Mailing Address - State:FL
Mailing Address - Zip Code:32569-1735
Mailing Address - Country:US
Mailing Address - Phone:850-226-9012
Mailing Address - Fax:
Practice Address - Street 1:446 RACETRACK RD NW UNIT C
Practice Address - Street 2:
Practice Address - City:FORT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32547-1544
Practice Address - Country:US
Practice Address - Phone:850-226-9012
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-09
Last Update Date:2023-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY49710993246RM2200X, 261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
No246RM2200XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyMedical LaboratoryGroup - Multi-Specialty