Provider Demographics
NPI:1689954760
Name:IRAHETA ABREGO, MARIO ALBERTO (MD)
Entity type:Individual
Prefix:
First Name:MARIO
Middle Name:ALBERTO
Last Name:IRAHETA ABREGO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:MARIO
Other - Middle Name:A
Other - Last Name:IRAHETA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:900 S PINE ISLAND RD STE 800
Mailing Address - Street 2:
Mailing Address - City:PLANTATION
Mailing Address - State:FL
Mailing Address - Zip Code:33324-3923
Mailing Address - Country:US
Mailing Address - Phone:904-354-6868
Mailing Address - Fax:904-358-3067
Practice Address - Street 1:1714 N MAIN ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32206-4404
Practice Address - Country:US
Practice Address - Phone:904-354-6868
Practice Address - Fax:904-358-3067
Is Sole Proprietor?:No
Enumeration Date:2011-08-22
Last Update Date:2021-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME147054208000000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL108158500Medicaid