Provider Demographics
NPI:1972234243
Name:BLONDIN FERNANDEZ, MARIO SERGIO
Entity type:Individual
Prefix:
First Name:MARIO
Middle Name:SERGIO
Last Name:BLONDIN FERNANDEZ
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 1:4455 SW 34TH ST APT X126
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32608-6550
Mailing Address - Country:US
Mailing Address - Phone:786-759-3645
Mailing Address - Fax:
Practice Address - Street 1:4455 SW 34TH ST APT X126
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32608-6550
Practice Address - Country:US
Practice Address - Phone:786-759-3645
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-18
Last Update Date:2022-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
NONEOtherNONE