Provider Demographics
NPI:1952371312
Name:MANTINEO, JOHNNA (DO)
Entity type:Individual
Prefix:DR
First Name:JOHNNA
Middle Name:
Last Name:MANTINEO
Suffix:
Gender:F
Credentials:DO
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 730729
Mailing Address - Street 2:
Mailing Address - City:ORMOND BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32173-0729
Mailing Address - Country:US
Mailing Address - Phone:386-231-6300
Mailing Address - Fax:386-322-6165
Practice Address - Street 1:5535 S WILLIAMSON BLVD
Practice Address - Street 2:SUITE 700
Practice Address - City:PORT ORANGE
Practice Address - State:FL
Practice Address - Zip Code:32128-8311
Practice Address - Country:US
Practice Address - Phone:386-231-6300
Practice Address - Fax:386-322-6165
Is Sole Proprietor?:No
Enumeration Date:2006-01-26
Last Update Date:2012-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS0005684207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
80256XMedicare ID - Type Unspecified
FLE74937Medicare UPIN