Provider Demographics
NPI:1316655970
Name:TORRES, MARIO DE JESUS
Entity type:Individual
Prefix:
First Name:MARIO
Middle Name:DE JESUS
Last Name:TORRES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:745 E LOWELL ST
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33805-3041
Mailing Address - Country:US
Mailing Address - Phone:646-377-6293
Mailing Address - Fax:
Practice Address - Street 1:200 AVENUE F NE
Practice Address - Street 2:
Practice Address - City:WINTER HAVEN
Practice Address - State:FL
Practice Address - Zip Code:33881-4193
Practice Address - Country:US
Practice Address - Phone:863-293-1121
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-11
Last Update Date:2022-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11022038367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty