Provider Demographics
NPI:1316143860
Name:MANSILLA MEDICAL PRACTICE, PC
Entity type:Organization
Organization Name:MANSILLA MEDICAL PRACTICE, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:OLIVIA
Authorized Official - Middle Name:ANA KAROLIN
Authorized Official - Last Name:MANSILLA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:804-379-3100
Mailing Address - Street 1:360 BROWN'S HILL CT.
Mailing Address - Street 2:
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:VA
Mailing Address - Zip Code:23114
Mailing Address - Country:US
Mailing Address - Phone:804-379-3100
Mailing Address - Fax:804-379-3200
Practice Address - Street 1:360 BROWN'S HILL CT.
Practice Address - Street 2:
Practice Address - City:MIDLOTHIAN
Practice Address - State:VA
Practice Address - Zip Code:23114
Practice Address - Country:US
Practice Address - Phone:804-379-3100
Practice Address - Fax:804-379-3200
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-22
Last Update Date:2009-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101229981207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAC08725Medicare PIN