Provider Demographics
NPI:1417739517
Name:MYA INTERNAL MEDICINE, INC
Entity type:Organization
Organization Name:MYA INTERNAL MEDICINE, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INTERNAL MEDICINE DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ADALGIZA
Authorized Official - Middle Name:ELENA
Authorized Official - Last Name:COSTA MORON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:407-967-1579
Mailing Address - Street 1:6886 PIAZZA GRANDE AVE APT 1201
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32835-8776
Mailing Address - Country:US
Mailing Address - Phone:407-967-1579
Mailing Address - Fax:
Practice Address - Street 1:6718 LAKE NONA BLVD STE 120
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32827-7984
Practice Address - Country:US
Practice Address - Phone:321-400-0451
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-10-16
Last Update Date:2024-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service