MEDICARE: FANEL MITIAL

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	171W00000X	Contractor		FL

General Provider Information

NPI Number	:	1174268395
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	FANEL MITIAL

Provider Business Mailing Address
First Line	:	1523 ELMHURST CIR SE
Second Line	:
City	:	PALM BAY
State	:	FL
Zip	:	32909-8833
Country	:	US
Telephone Number	:	561-727-7359
Fax Number	:

Provider Business Practice Location Address
First Line	:	1523 ELMHURST CIR SE
Second Line	:
City	:	PALM BAY
State	:	FL
Zip	:	32909-8833
Country	:	US
Telephone Number	:	561-727-7359
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/02/2022
Last Update Date	:	05/02/2022

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Directions to “ FANEL MITIAL ” Practice Location

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