MEDICARE: ANSELMO MANUEL MENDIVE, MD. PA.

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	207Q00000X	Family Medicine Physician	ME56412	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
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1619011228
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ANSELMO MANUEL MENDIVE, MD. PA.

Provider Business Mailing Address
First Line	:	4601 NW 199TH ST
Second Line	:	SUITE E
City	:	MIAMI GARDENS
State	:	FL
Zip	:	33055-1508
Country	:	US
Telephone Number	:	305-801-7030
Fax Number	:	305-623-7044

Provider Business Practice Location Address
First Line	:	4601 NW 199TH ST
Second Line	:	SUITE E
City	:	MIAMI GARDENS
State	:	FL
Zip	:	33055-1508
Country	:	US
Telephone Number	:	305-801-7030
Fax Number	:	305-623-7044

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	MRS. YIN GARCIA
Credential	:
Telephone Number	:	305-801-7030

Provider Enumeration Date	:	02/16/2007
Last Update Date	:	01/31/2012

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