Basic Information
| Provider Information | |||||||||
| NPI: | 1760836829 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MACIAS MENDOZA | ||||||||
| FirstName: | ANDREA | ||||||||
| MiddleName: | |||||||||
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| OtherLastName: | MACIAS | ||||||||
| OtherFirstName: | ANDREA | ||||||||
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| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 100254 | ||||||||
| Address2: | |||||||||
| City: | GAINESVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 326100254 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3522738610 | ||||||||
| FaxNumber: | 3522738612 | ||||||||
| Practice Location | |||||||||
| Address1: | 1600 SW ARCHER RD | ||||||||
| Address2: | |||||||||
| City: | GAINESVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 326101951 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3522738610 | ||||||||
| FaxNumber: | 3522738612 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/14/2016 | ||||||||
| LastUpdateDate: | 03/03/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 03/03/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207L00000X | ME142622 | FL | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 107257400 | 05 | FL | MEDICAID |