Provider Demographics
NPI:1740972157
Name:MITHIL, CAROL
Entity type:Individual
Prefix:
First Name:CAROL
Middle Name:
Last Name:MITHIL
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 1:3425 BAYSIDE LAKES BLVD SE STE 103
Mailing Address - Street 2:
Mailing Address - City:PALM BAY
Mailing Address - State:FL
Mailing Address - Zip Code:32909-6867
Mailing Address - Country:US
Mailing Address - Phone:321-210-1309
Mailing Address - Fax:
Practice Address - Street 1:231 ABERNATHY CIR SE
Practice Address - Street 2:
Practice Address - City:PALM BAY
Practice Address - State:FL
Practice Address - Zip Code:32909-2346
Practice Address - Country:US
Practice Address - Phone:321-210-1309
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-24
Last Update Date:2023-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLM340100664130172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver