Healthcare Provider Details

I. General information

NPI: 1457181455
Provider Name (Legal Business Name): JOSE EDUARDO FRIAS MANTILLA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/05/2024
Last Update Date: 08/05/2024
Certification Date: 08/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 BD DECARIE
MONTREAL QUEBEC
H3T1V5
CA

IV. Provider business mailing address

608-5160 AVENUE DECELLES
MONTREAL QUEBEC
H3T1V5
CA

V. Phone/Fax

Practice location:
  • Phone: 514-412-4400
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberR31031
License Number StateZZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: