MEDICARE: JOSE OSCAR MANTILLA-RIVAS

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	101YP2500X	Professional Counselor	PC009876	PA
2	390200000X	Student in an Organized Health Care Education/Training Program	MT215100	PA
3	2084P0800X	Psychiatry Physician	MD477620	PA

General Provider Information

NPI Number	:	1619458676
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOSE OSCAR MANTILLA-RIVAS

Provider Business Mailing Address
First Line	:	6501 ARLINGTON EXPRESSWAY
Second Line	:	B105#7069
City	:	JACKSONVILLE
State	:	FL
Zip	:	32211
Country	:	US
Telephone Number	:	904-201-9110
Fax Number	:	757-432-3134

Provider Business Practice Location Address
First Line	:	6501 ARLINGTON EXPRESSWAY
Second Line	:	B105#7069
City	:	JACKSONVILLE
State	:	FL
Zip	:	32211-5779
Country	:	US
Telephone Number	:	904-201-9110
Fax Number	:	757-432-3134

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

Provider Enumeration Date	:	08/27/2018
Last Update Date	:	01/08/2026

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