Basic Information
Provider Information | |||||||||
NPI: | 1336259886 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MAMMINO | ||||||||
FirstName: | JERE | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | DO | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2600 LAKE LUCIEN DR STE 180 | ||||||||
Address2: |   | ||||||||
City: | MAITLAND | ||||||||
State: | FL | ||||||||
PostalCode: | 327517235 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4078752080 | ||||||||
FaxNumber: | 4078750518 | ||||||||
Practice Location | |||||||||
Address1: | 1410 W BROADWAY ST STE 102 | ||||||||
Address2: |   | ||||||||
City: | OVIEDO | ||||||||
State: | FL | ||||||||
PostalCode: | 327656537 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4073592100 | ||||||||
FaxNumber: | 4073595445 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/30/2006 | ||||||||
LastUpdateDate: | 07/08/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207N00000X | OS6033 | FL | Y |   | Allopathic & Osteopathic Physicians | Dermatology |   |
No ID Information.