Provider Demographics
NPI:1215679402
Name:BRITO MANTILLA, GISELLE (MD)
Entity type:Individual
Prefix:
First Name:GISELLE
Middle Name:
Last Name:BRITO MANTILLA
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:PO BOX 2147
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33902-2147
Mailing Address - Country:US
Mailing Address - Phone:239-468-0150
Mailing Address - Fax:239-343-4065
Practice Address - Street 1:23450 VIA COCONUT PT
Practice Address - Street 2:
Practice Address - City:ESTERO
Practice Address - State:FL
Practice Address - Zip Code:34135-1877
Practice Address - Country:US
Practice Address - Phone:239-468-0150
Practice Address - Fax:239-343-4065
Is Sole Proprietor?:No
Enumeration Date:2022-04-08
Last Update Date:2025-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME174553207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL127379200Medicaid