=====================================================
General NPI Number Information
=====================================================
NPI Number | 1619011228
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ANSELMO MANUEL MENDIVE, MD. PA.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/16/2007
-----------------------------------------------------
Last Update Date | 01/31/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4601 NW 199TH ST SUITE E
-----------------------------------------------------
City | MIAMI GARDENS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33055-1508
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-801-7030
-----------------------------------------------------
Fax | 305-623-7044
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4601 NW 199TH ST SUITE E
-----------------------------------------------------
City | MIAMI GARDENS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33055-1508
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-801-7030
-----------------------------------------------------
Fax | 305-623-7044
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | MRS. YIN GARCIA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 305-801-7030
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | ME56412
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------