Provider Demographics
NPI:1174268395
Name:MITIAL, FANEL
Entity Type:Individual
Prefix:
First Name:FANEL
Middle Name:
Last Name:MITIAL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1523 ELMHURST CIR SE
Mailing Address - Street 2:
Mailing Address - City:PALM BAY
Mailing Address - State:FL
Mailing Address - Zip Code:32909-8833
Mailing Address - Country:US
Mailing Address - Phone:561-727-7359
Mailing Address - Fax:
Practice Address - Street 1:1523 ELMHURST CIR SE
Practice Address - Street 2:
Practice Address - City:PALM BAY
Practice Address - State:FL
Practice Address - Zip Code:32909-8833
Practice Address - Country:US
Practice Address - Phone:561-727-7359
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-02
Last Update Date:2022-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor