Provider Demographics
NPI:1720085525
Name:MANSILLA, ALBERTO (MD)
Entity type:Individual
Prefix:
First Name:ALBERTO
Middle Name:
Last Name:MANSILLA
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 1:2600 WESTHALL LN FL 4
Mailing Address - Street 2:
Mailing Address - City:MAITLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32751-7102
Mailing Address - Country:US
Mailing Address - Phone:407-200-2355
Mailing Address - Fax:
Practice Address - Street 1:601 E ROLLINS ST
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32803-1248
Practice Address - Country:US
Practice Address - Phone:407-200-2355
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-07
Last Update Date:2023-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME825842085R0202X, 2085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL300124478OtherRR MEDICARE
FL261587800Medicaid
FL01683OtherBCBS OF FLORIDA
FL01683AMedicare PIN
FL300124478OtherRR MEDICARE
FLH45311Medicare UPIN