Provider Demographics
NPI:1366708323
Name:AGARD, MALISA (MD)
Entity type:Individual
Prefix:
First Name:MALISA
Middle Name:
Last Name:AGARD
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 1:21 W COLUMBIA ST
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32806-2028
Mailing Address - Country:US
Mailing Address - Phone:321-841-6600
Mailing Address - Fax:321-841-4085
Practice Address - Street 1:21 W COLUMBIA ST
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32806-2028
Practice Address - Country:US
Practice Address - Phone:321-841-6600
Practice Address - Fax:321-841-4085
Is Sole Proprietor?:No
Enumeration Date:2012-04-04
Last Update Date:2016-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME123840207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLME123840OtherMEDICAL LICENSE
FL015089700Medicaid
FLIF334ZMedicare PIN