Provider Demographics
NPI:1427229384
Name:MENDIVE, ANSELMO M (MD)
Entity Type:Individual
Prefix:DR
First Name:ANSELMO
Middle Name:M
Last Name:MENDIVE
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:4601 NW 199TH ST
Mailing Address - Street 2:SUITE E
Mailing Address - City:MIAMI GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33055-1508
Mailing Address - Country:US
Mailing Address - Phone:305-801-7030
Mailing Address - Fax:305-274-4032
Practice Address - Street 1:4601 NW 199TH ST
Practice Address - Street 2:SUITE E
Practice Address - City:MIAMI GARDENS
Practice Address - State:FL
Practice Address - Zip Code:33055-1508
Practice Address - Country:US
Practice Address - Phone:305-801-7030
Practice Address - Fax:305-274-4032
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-19
Last Update Date:2008-03-24
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLME56412207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL048992101Medicaid
FL048992100Medicaid
FL08462Medicare PIN