1477761898 NPI number — DR. ANGEL RICARDO MESA

Table of content: DR. ANGEL RICARDO MESA (NPI 1477761898)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477761898 NPI number — DR. ANGEL RICARDO MESA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MESA
Provider First Name:
ANGEL
Provider Middle Name:
RICARDO
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1477761898
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/28/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1870 FOREST HILL BLVD
Provider Second Line Business Mailing Address:
STE 101
Provider Business Mailing Address City Name:
WEST PALM BEACH
Provider Business Mailing Address State Name:
FL - FLORIDA
Provider Business Mailing Address Postal Code:
33406
Provider Business Mailing Address Country Code:
UM
Provider Business Mailing Address Telephone Number:
561-766-2373
Provider Business Mailing Address Fax Number:
561-766-2615

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1870 FOREST HILL BLVD
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
WEST PALM BEACH
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33406-8901
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
561-766-2373
Provider Business Practice Location Address Fax Number:
561-766-2615
Provider Enumeration Date:
05/18/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  ME99661 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 279227300 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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