Healthcare Provider Details

I. General information

NPI: 1114985199
Provider Name (Legal Business Name): CONSTANTINO GILBERTO MENDIETA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/01/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2310 S DIXIE HWY
MIAMI FL
33133-2314
US

IV. Provider business mailing address

3637 ROYAL PALM AVE
MIAMI FL
33133-6226
US

V. Phone/Fax

Practice location:
  • Phone: 305-860-0717
  • Fax: 305-858-6570
Mailing address:
  • Phone: 305-860-0717
  • Fax: 305-858-6570

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number070055
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: