Provider Demographics
NPI:1417165101
Name:INTERVENTIONAL NEUROLOGY
Entity Type:Organization
Organization Name:INTERVENTIONAL NEUROLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:ANTONIO
Authorized Official - Middle Name:
Authorized Official - Last Name:MESA
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:305-670-7650
Mailing Address - Street 1:PO BOX 43-1405
Mailing Address - Street 2:
Mailing Address - City:SOUTH MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33243-1405
Mailing Address - Country:US
Mailing Address - Phone:305-670-7650
Mailing Address - Fax:305-670-7657
Practice Address - Street 1:11880 SW 40TH ST
Practice Address - Street 2:SUITE 18
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33175-3574
Practice Address - Country:US
Practice Address - Phone:305-670-7650
Practice Address - Fax:305-670-7657
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-18
Last Update Date:2007-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS87112084N0400X, 2084P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P2900XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPain MedicineGroup - Single Specialty
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
K5999Medicare PIN
FLH78178Medicare UPIN