MEDICARE: VASCULAR AND EMBOLIZATION SPECIALISTS PLLC

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	2085R0204X	Vascular & Interventional Radiology Physician

General Provider Information

NPI Number	:	1629846910
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	VASCULAR AND EMBOLIZATION SPECIALISTS PLLC

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	:	OWNER
Name	:	DEREK MITTLEIDER
Credential	:	MD
Telephone Number	:	207-749-9036

Provider Enumeration Date	:	12/15/2023
Last Update Date	:	12/15/2023

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