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General NPI Number Information
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NPI Number | 1629846910
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Entity Type | Organization
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Legal Business Name | VASCULAR AND EMBOLIZATION SPECIALISTS PLLC
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Dates
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Enumeration Date | 12/15/2023
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Last Update Date | 12/15/2023
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Provider Practice Location Address
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Address Line | 2300 STATE ROAD 524 STE 106
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City | COCOA
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State | FL
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Zip | 32926-5894
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Country | US
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Telephone | 321-321-3001
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Fax | 321-321-4001
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Provider Business Mailing Address
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Address Line | 2300 STATE ROAD 524 STE 106
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City | COCOA
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State | FL
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Zip | 32926-5894
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Country | US
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Telephone | 321-321-3001
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Fax | 321-321-4001
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Authorized Official
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Title or Position | OWNER
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Name | DEREK MITTLEIDER
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Credential | MD
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Telephone | 207-749-9036
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2085R0204X
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Taxonomy Name | Vascular & Interventional Radiology Physician
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License Number |
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License Number State |
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