Provider Demographics
NPI:1144925777
Name:MAYORAL, MARK ANTHONY (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:ANTHONY
Last Name:MAYORAL
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 1:3531 SW 87TH CT
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33165-4311
Mailing Address - Country:US
Mailing Address - Phone:786-877-7524
Mailing Address - Fax:
Practice Address - Street 1:3531 SW 87TH CT
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33165-4311
Practice Address - Country:US
Practice Address - Phone:786-877-7524
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-03
Last Update Date:2024-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301512643207Q00000X
CO73845207Q00000X
GA101353207Q00000X
MN77878207Q00000X
390200000X
FL38039207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program