Provider Demographics
NPI:1295739241
Name:MANTECON, ISRAEL JUAN
Entity type:Individual
Prefix:
First Name:ISRAEL
Middle Name:JUAN
Last Name:MANTECON
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 1:1723 LUCERNE TER STE 100
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32806-2916
Mailing Address - Country:US
Mailing Address - Phone:407-738-4200
Mailing Address - Fax:
Practice Address - Street 1:1723 LUCERNE TER STE 100
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32806-2916
Practice Address - Country:US
Practice Address - Phone:407-738-4200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-08
Last Update Date:2023-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME54748207RC0000X, 207UN0901X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207UN0901XAllopathic & Osteopathic PhysiciansNuclear MedicineNuclear Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL374977100Medicaid
FLME54748OtherMEDICAL LICENSE
FLME54748OtherMEDICAL LICENSE
FL25074XMedicare PIN