Provider Demographics
NPI:1962732388
Name:JUAN A MANTILLA MD PA
Entity type:Organization
Organization Name:JUAN A MANTILLA MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JUAN
Authorized Official - Middle Name:ALBERTO
Authorized Official - Last Name:MANTILLA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:305-279-4222
Mailing Address - Street 1:11400 N KENDALL DR STE 204
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33176-1029
Mailing Address - Country:US
Mailing Address - Phone:305-279-2222
Mailing Address - Fax:305-501-2031
Practice Address - Street 1:11400 N KENDALL DR STE 204
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33176-1029
Practice Address - Country:US
Practice Address - Phone:305-279-2222
Practice Address - Fax:305-501-2031
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-07
Last Update Date:2021-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME77038207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL266223000Medicaid
FL266223000Medicaid