1295997666 NPI number — DR. BERNADETTE C. ANTONYRAJAH MD

Table of content: DR. BERNADETTE C. ANTONYRAJAH MD (NPI 1295997666)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295997666 NPI number — DR. BERNADETTE C. ANTONYRAJAH MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ANTONYRAJAH
Provider First Name:
BERNADETTE
Provider Middle Name:
C.
Provider Name Prefix Text:
DR.
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:
1295997666
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/15/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 917770
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ORLANDO
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32891-0001
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
813-821-8038
Provider Business Mailing Address Fax Number:
813-974-4325

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1111 6TH AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DES MOINES
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
50314-2613
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
515-247-3330
Provider Business Practice Location Address Fax Number:
515-643-8839
Provider Enumeration Date:
06/27/2008

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: 207PP0204X , with the licence number:  ME113647 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2080P0203X , with the licence number: ME113647 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2080P0203X , with the licence number: MD-43932 , registered in the state of IA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208000000X , with the licence number: ME113647 , 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: 006240200 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 14LE6 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 006240200 . 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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