MEDICARE: DR. CONSTANTINO GILBERTO MENDIETA MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208200000X	Plastic Surgery Physician	070055	FL

General Provider Information

NPI Number	:	1114985199
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CONSTANTINO GILBERTO MENDIETA MD

Provider Business Mailing Address
First Line	:	3637 ROYAL PALM AVE
Second Line	:
City	:	MIAMI
State	:	FL
Zip	:	33133-6226
Country	:	US
Telephone Number	:	305-860-0717
Fax Number	:	305-858-6570

Provider Business Practice Location Address
First Line	:	2310 S DIXIE HWY
Second Line	:
City	:	MIAMI
State	:	FL
Zip	:	33133-2314
Country	:	US
Telephone Number	:	305-860-0717
Fax Number	:	305-858-6570

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/01/2006
Last Update Date	:	07/08/2007

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