Provider Demographics
NPI:1366238073
Name:DORTA, MARY A
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:A
Last Name:DORTA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1104 E FOWLER AVE UNIT 100
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33612-5404
Mailing Address - Country:US
Mailing Address - Phone:813-705-7557
Mailing Address - Fax:
Practice Address - Street 1:1104 E FOWLER AVE UNIT 100
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33612-5404
Practice Address - Country:US
Practice Address - Phone:813-705-7557
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-04-18
Last Update Date:2025-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program