Provider Demographics
NPI:1700807062
Name:MENSA, EDITH (MD)
Entity Type:Individual
Prefix:DR
First Name:EDITH
Middle Name:
Last Name:MENSA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:631 PALM SPRINGS DR
Mailing Address - Street 2:SUITE 117
Mailing Address - City:ALTAMONTE SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32701-7854
Mailing Address - Country:US
Mailing Address - Phone:407-339-5600
Mailing Address - Fax:407-339-5602
Practice Address - Street 1:631 PALM SPRINGS DR
Practice Address - Street 2:SUITE 117
Practice Address - City:ALTAMONTE SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:32701-7854
Practice Address - Country:US
Practice Address - Phone:407-339-5600
Practice Address - Fax:407-339-5602
Is Sole Proprietor?:No
Enumeration Date:2006-07-22
Last Update Date:2010-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0069717207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL32266ZMedicare ID - Type Unspecified
FLG34667Medicare UPIN