Provider Demographics
NPI:1487603445
Name:PRADO, MARTIN GINO FERNANDEZ (MD)
Entity type:Individual
Prefix:
First Name:MARTIN GINO
Middle Name:FERNANDEZ
Last Name:PRADO
Suffix:
Gender:M
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:PO BOX 945385
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30394-5385
Mailing Address - Country:US
Mailing Address - Phone:386-822-9410
Mailing Address - Fax:386-469-0045
Practice Address - Street 1:1070 N STONE ST
Practice Address - Street 2:SUITE D
Practice Address - City:DELAND
Practice Address - State:FL
Practice Address - Zip Code:32720-0919
Practice Address - Country:US
Practice Address - Phone:386-822-9410
Practice Address - Fax:386-469-0045
Is Sole Proprietor?:No
Enumeration Date:2006-05-08
Last Update Date:2023-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME78262174400000X, 207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL269724600Medicaid
FL593256803OtherTAX ID
FL593256803OtherTAX ID
G93381Medicare UPIN