=====================================================
General NPI Number Information
=====================================================
NPI Number | 1477967511
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MESA MEDICAL LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/17/2014
-----------------------------------------------------
Last Update Date | 06/17/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1870 FOREST HILL BLVD
-----------------------------------------------------
City | WEST PALM BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33406-6057
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-766-2373
-----------------------------------------------------
Fax | 561-766-2615
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1870 FOREST HILL BLVD STE 101
-----------------------------------------------------
City | WEST PALM BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33406-6057
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-766-2373
-----------------------------------------------------
Fax | 561-766-2615
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DOCTOR
-----------------------------------------------------
Name | DR. ANGEL R MESA
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 561-766-2373
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | ME99661
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------