Basic Information
| Provider Information | |||||||||
| NPI: | 1295739241 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MANTECON | ||||||||
| FirstName: | ISRAEL | ||||||||
| MiddleName: | JUAN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7236 STONEROCK CIR | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328198000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3218416444 | ||||||||
| FaxNumber: | 4076501307 | ||||||||
| Practice Location | |||||||||
| Address1: | 1222 S ORANGE AVE | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328061215 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4076501300 | ||||||||
| FaxNumber: | 4076501307 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/08/2005 | ||||||||
| LastUpdateDate: | 04/04/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207UN0901X | ME54748 | FL | N | Allopathic & Osteopathic Physicians | Nuclear Medicine | Nuclear Cardiology | 207RC0000X | ME54748 | FL | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 374977100 | 05 | FL | MEDICAID | ME54748 | 01 | FL | MEDICAL LICENSE | OTHER |