Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 208000000X | Pediatrician | ME61885 | FL |
N | 2080A0000X | Adolescent Medicine | ME0061885 | FL |
N | 2080P0203X | Pediatric Critical Care Doctor | ME0061885 | FL |
NPI | 1154498772 |
---|---|
Provider Name | Dr. Mariano R Fiallos |
First Address | Tampa, FL 33613-4613 |
Second Address | Tampa, FL 33613-4613 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 29/11/2006 |
Last Update Date | 10/02/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
11314867 | CAQH (01) | FL |
254343500 | (05) | FL |
43953 | BLUE CROSS (01) | FL |
F09310 | UPIN (01) | FL |