MEDICARE: DEREK MITTLEIDER M.D.

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	2085R0202X	Diagnostic Radiology Physician	ME142152	FL
2	2085R0204X	Vascular & Interventional Radiology Physician	ME14152	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1538234414
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DEREK MITTLEIDER M.D.

Provider Business Mailing Address
First Line	:	2300 STATE ROAD 524 STE 106
Second Line	:
City	:	COCOA
State	:	FL
Zip	:	32926-5894
Country	:	US
Telephone Number	:	321-321-3001
Fax Number	:	321-321-4001

Provider Business Practice Location Address
First Line	:	2300 STATE ROAD 524 STE 106
Second Line	:
City	:	COCOA
State	:	FL
Zip	:	32926-5894
Country	:	US
Telephone Number	:	321-321-3001
Fax Number	:	321-321-4001

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

Provider Enumeration Date	:	11/23/2006
Last Update Date	:	12/15/2023

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