1114124112 NPI number — SHRADHA POKHAREL MD

Table of content: SHRADHA POKHAREL MD (NPI 1114124112)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114124112 NPI number — SHRADHA POKHAREL MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
POKHAREL
Provider First Name:
SHRADHA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1114124112
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/08/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2021 KINGSLEY AVE
Provider Second Line Business Mailing Address:
SUITE 101
Provider Business Mailing Address City Name:
ORANGE PARK
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32073-5174
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
904-298-2113
Provider Business Mailing Address Fax Number:
904-298-1922

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2021 KINGSLEY AVE
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
ORANGE PARK
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32073-5174
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-298-2113
Provider Business Practice Location Address Fax Number:
904-298-1922
Provider Enumeration Date:
07/02/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207RI0200X , with the licence number:  ME107854 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 003140199A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 149FM . This is a "BCBS" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 002671500 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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