MEDICARE: DR. JUAN ALBERTO MANTILLA 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	207R00000X	Internal Medicine Physician	ME 77038	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	:	1699715292
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JUAN ALBERTO MANTILLA MD

Provider Business Mailing Address
First Line	:	11400 N KENDALL DR STE 204
Second Line	:
City	:	MIAMI
State	:	FL
Zip	:	33176-1029
Country	:	US
Telephone Number	:	305-279-2222
Fax Number	:	305-501-2031

Provider Business Practice Location Address
First Line	:	11400 N KENDALL DR STE 204
Second Line	:
City	:	MIAMI
State	:	FL
Zip	:	33176-1029
Country	:	US
Telephone Number	:	305-279-2222
Fax Number	:	305-501-2031

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

Provider Enumeration Date	:	06/08/2006
Last Update Date	:	06/29/2021

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