Healthcare Provider Details

I. General information

NPI: 1144420753
Provider Name (Legal Business Name): JOSE MENA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: JOSE R. MENA-MERCADO MD

II. Dates (important events)

Enumeration Date: 07/21/2007
Last Update Date: 01/28/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1611 NW 12TH AVE SUITE L105 (D460)
MIAMI FL
33136-1005
US

IV. Provider business mailing address

1611 NW 12TH AVE P. O. BOX 016960 (D461)
MIAMI FL
33136-1005
US

V. Phone/Fax

Practice location:
  • Phone: 305-585-1320
  • Fax: 305-585-1340
Mailing address:
  • Phone: 305-585-1320
  • Fax: 305-585-1340

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License NumberME 102021
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: