Provider Demographics
NPI:1316992365
Name:BOLOGNA, MARCO TEODORO (MD)
Entity type:Individual
Prefix:
First Name:MARCO
Middle Name:TEODORO
Last Name:BOLOGNA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 198054
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30384-8054
Mailing Address - Country:US
Mailing Address - Phone:786-594-6880
Mailing Address - Fax:
Practice Address - Street 1:8950 N KENDALL DR STE 506W
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33176-2127
Practice Address - Country:US
Practice Address - Phone:786-596-1230
Practice Address - Fax:786-533-9297
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-24
Last Update Date:2022-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME977662086S0129X, 208G00000X
AL252422086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
No2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL009932919Medicaid
AL010033CI37553OtherSECTION 1011
AL009932702Medicaid
AL051530105OtherBLUE CROSS
FL277690100Medicaid
AL051530103OtherBLUE CROSS
MS02208294OtherMISSISSIPPI MEDICAID
AL051530105OtherBLUE CROSS
AL051556470Medicare ID - Type Unspecified