Provider Demographics
NPI:1164455119
Name:MIRABELLI, JORGE LUIS ANIBAL (MD)
Entity Type:Individual
Prefix:MR
First Name:JORGE
Middle Name:LUIS ANIBAL
Last Name:MIRABELLI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:570 MEMORIAL CIR
Mailing Address - Street 2:SUITE 200
Mailing Address - City:ORMOND BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32174-5002
Mailing Address - Country:US
Mailing Address - Phone:386-944-9813
Mailing Address - Fax:386-317-0664
Practice Address - Street 1:570 MEMORIAL CIR
Practice Address - Street 2:SUITE 200
Practice Address - City:ORMOND BEACH
Practice Address - State:FL
Practice Address - Zip Code:32174-5002
Practice Address - Country:US
Practice Address - Phone:386-451-2346
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-09
Last Update Date:2024-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME1019682084N0400X
OH35-0847092084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL0001216-00Medicaid
GA670456672AMedicaid
OH2504810Medicaid
P00174902OtherMCR RR
I15939Medicare UPIN
GA670456672AMedicaid
OHMI4142091Medicare PIN