Provider Demographics
NPI:1962825182
Name:MANTLO, DEREK
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:
Last Name:MANTLO
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:PO BOX 793
Mailing Address - Street 2:
Mailing Address - City:ALACHUA
Mailing Address - State:FL
Mailing Address - Zip Code:32616-0793
Mailing Address - Country:US
Mailing Address - Phone:352-275-1652
Mailing Address - Fax:
Practice Address - Street 1:20688 NW 252ND ST
Practice Address - Street 2:
Practice Address - City:HIGH SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:32643-8419
Practice Address - Country:US
Practice Address - Phone:352-275-1652
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-01-23
Last Update Date:2014-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor