Basic Information
| Provider Information | |||||||||
| NPI: | 1861841348 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | JESSICA MANTILLA MD INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 788 | ||||||||
| Address2: | |||||||||
| City: | HEMET | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925460788 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9519296260 | ||||||||
| FaxNumber: | 9517652855 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 S RAYMOND AVE | ||||||||
| Address2: | |||||||||
| City: | ALHAMBRA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 918013166 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9519296260 | ||||||||
| FaxNumber: | 9517652855 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/06/2016 | ||||||||
| LastUpdateDate: | 06/06/2016 | ||||||||
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| AuthorizedOfficialLastName: | MANTILLA | ||||||||
| AuthorizedOfficialFirstName: | JESSICA | ||||||||
| AuthorizedOfficialMiddleName: | P | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9519296260 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RI0200X | A110850 | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Infectious Disease |
No ID Information.