Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 156FX1100X | Ophthalmic | ||
Y | 208D00000X | General Practice Physician | 480-05 | ZZ |
NPI | 1508255415 |
---|---|
Provider Name | Massiel R. Mena |
First Address | Kissimmee, FL 34743-9408 |
Second Address | Kissimmee, FL 34744-1604 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 15/01/2015 |
Last Update Date | 15/01/2015 |