1912954439 NPI number — FLORIDA INTERNAL MEDICINE, PL

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912954439 NPI number — FLORIDA INTERNAL MEDICINE, PL

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FLORIDA INTERNAL MEDICINE, PL
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1912954439
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/10/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3016 PALERMO CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MOUNT DORA
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32757-6527
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
352-383-8209
Provider Business Mailing Address Fax Number:
352-383-8209

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
620 S LAKE ST
Provider Second Line Business Practice Location Address:
SUITE# 6
Provider Business Practice Location Address City Name:
LEESBURG
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34748-6059
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
352-365-0099
Provider Business Practice Location Address Fax Number:
352-315-0578
Provider Enumeration Date:
05/29/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BANALA
Authorized Official First Name:
DWARAKNADH
Authorized Official Middle Name:
R
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
352-365-0099

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  ME80590 , 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: 104106600 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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