Basic Information
| Provider Information | |||||||||
| NPI: | 1831599794 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MIMBELLA | ||||||||
| FirstName: | PAOLO | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 223190 | ||||||||
| Address2: | |||||||||
| City: | HOLLYWOOD | ||||||||
| State: | FL | ||||||||
| PostalCode: | 330223190 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3059745533 | ||||||||
| FaxNumber: | 3059745553 | ||||||||
| Practice Location | |||||||||
| Address1: | 21000 NE 28TH AVE STE 104 | ||||||||
| Address2: | |||||||||
| City: | AVENTURA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331801421 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3059745533 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/28/2014 | ||||||||
| LastUpdateDate: | 04/07/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/07/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2081P2900X | ME15107 | FL | Y | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | 402548801 | 05 | TX | MEDICAID |