Healthcare Provider Details

I. General information

NPI: 1083547582
Provider Name (Legal Business Name): FABIAN MANTILLA DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/04/2026
Last Update Date: 06/04/2026
Certification Date: 06/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7727 LAKE UNDERHILL RD
ORLANDO FL
32822-8224
US

IV. Provider business mailing address

2501 N ORANGE AVE STE 235
ORLANDO FL
32804-4659
US

V. Phone/Fax

Practice location:
  • Phone: 407-303-8110
  • Fax:
Mailing address:
  • Phone: 201-354-8986
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberUO11497
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: