Provider Demographics
NPI:1447251061
Name:LORENZO, MAYRA L (MD)
Entity type:Individual
Prefix:DR
First Name:MAYRA
Middle Name:L
Last Name:LORENZO
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 1:14690 SPRING HILL DR
Mailing Address - Street 2:SUITE 100 ATTN:CREDENTIALING
Mailing Address - City:SPRING HILL
Mailing Address - State:FL
Mailing Address - Zip Code:34609-8102
Mailing Address - Country:US
Mailing Address - Phone:352-799-0046
Mailing Address - Fax:352-606-2857
Practice Address - Street 1:12150 SEMINOLE BLVD
Practice Address - Street 2:
Practice Address - City:LARGO
Practice Address - State:FL
Practice Address - Zip Code:33778
Practice Address - Country:US
Practice Address - Phone:727-216-6188
Practice Address - Fax:727-216-6242
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-04
Last Update Date:2017-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME59120207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
E08564Medicare PIN
FLBR467YMedicare PIN
FL12987AMedicare ID - Type Unspecified