Basic Information
| Provider Information | |||||||||
| NPI: | 1962490037 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MONREAL | ||||||||
| FirstName: | MYRNA | ||||||||
| MiddleName: | C | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | CRISOSTOMO | ||||||||
| OtherFirstName: | MYRNA | ||||||||
| OtherMiddleName: | ROMULO | ||||||||
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| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1290 GOLFVIEW AVENUE | ||||||||
| Address2: | 4TH FLOOR ATTN BILLING DEPARTMENT | ||||||||
| City: | BARTOW | ||||||||
| State: | FL | ||||||||
| PostalCode: | 338306740 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8635197900 | ||||||||
| FaxNumber: | 8635197696 | ||||||||
| Practice Location | |||||||||
| Address1: | 111 N 11TH ST | ||||||||
| Address2: | |||||||||
| City: | HAINES CITY | ||||||||
| State: | FL | ||||||||
| PostalCode: | 338444325 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8634213204 | ||||||||
| FaxNumber: | 8634213210 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/12/2005 | ||||||||
| LastUpdateDate: | 08/11/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | ME37811 | FL | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 067027800 | 05 | FL | MEDICAID |