Provider Demographics
NPI:1629846910
Name:VASCULAR AND EMBOLIZATION SPECIALISTS PLLC
Entity Type:Organization
Organization Name:VASCULAR AND EMBOLIZATION SPECIALISTS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DEREK
Authorized Official - Middle Name:
Authorized Official - Last Name:MITTLEIDER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:207-749-9036
Mailing Address - Street 1:2300 STATE ROAD 524 STE 106
Mailing Address - Street 2:
Mailing Address - City:COCOA
Mailing Address - State:FL
Mailing Address - Zip Code:32926-5894
Mailing Address - Country:US
Mailing Address - Phone:321-321-3001
Mailing Address - Fax:321-321-4001
Practice Address - Street 1:2300 STATE ROAD 524 STE 106
Practice Address - Street 2:
Practice Address - City:COCOA
Practice Address - State:FL
Practice Address - Zip Code:32926-5894
Practice Address - Country:US
Practice Address - Phone:321-321-3001
Practice Address - Fax:321-321-4001
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-12-15
Last Update Date:2023-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional RadiologyGroup - Single Specialty