Provider Demographics
NPI:1992879944
Name:MAYORGA, RENE N (MD)
Entity type:Individual
Prefix:DR
First Name:RENE
Middle Name:N
Last Name:MAYORGA
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 1:14261 SW 120TH ST STE 110
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33186-7273
Mailing Address - Country:US
Mailing Address - Phone:305-378-1302
Mailing Address - Fax:305-378-1311
Practice Address - Street 1:14261 SW 120TH ST STE 110
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33186-7273
Practice Address - Country:US
Practice Address - Phone:305-378-1302
Practice Address - Fax:305-378-1311
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-20
Last Update Date:2010-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 54068207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL08688OtherBLUE CROSS BLUE SHIEL
2132789OtherAETNA
FL08668YMedicare ID - Type Unspecified
2132789OtherAETNA