Provider Demographics
NPI:1730180381
Name:GARCIA, MYRNA A (MD)
Entity type:Individual
Prefix:
First Name:MYRNA
Middle Name:A
Last Name:GARCIA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2540 N VOLUSIA AVE
Mailing Address - Street 2:
Mailing Address - City:ORANGE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32763-2842
Mailing Address - Country:US
Mailing Address - Phone:386-774-1263
Mailing Address - Fax:386-774-1838
Practice Address - Street 1:2540 N VOLUSIA AVE
Practice Address - Street 2:
Practice Address - City:ORANGE CITY
Practice Address - State:FL
Practice Address - Zip Code:32763-2842
Practice Address - Country:US
Practice Address - Phone:386-774-1263
Practice Address - Fax:386-774-1838
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-04
Last Update Date:2007-07-09
Deactivation Date:2006-03-22
Deactivation Code:
Reactivation Date:2006-03-28
Provider Licenses
StateLicense IDTaxonomies
FLME52909174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL52909OtherSTATE LICENSE NBR
FL08774Medicare ID - Type UnspecifiedMEDICARE NBR
FL52909OtherSTATE LICENSE NBR