1972658052 NPI number — GASTROENTEROLOGY AND NUTRITION SPECIALIST PA

Table of content: (NPI 1972658052)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972658052 NPI number — GASTROENTEROLOGY AND NUTRITION SPECIALIST PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GASTROENTEROLOGY AND NUTRITION SPECIALIST PA
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:
1972658052
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/09/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2880 S OSCEOLA AVE
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:
32806-5431
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
407-843-0443
Provider Business Mailing Address Fax Number:
407-843-0442

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2880 S OSCEOLA AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ORLANDO
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32806-5431
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
407-843-0443
Provider Business Practice Location Address Fax Number:
407-843-0442
Provider Enumeration Date:
01/25/2007

Additional Information

Authorized Official

Authorized Official Last Name:
MOHIUDDIN
Authorized Official First Name:
MUHAMMAD
Authorized Official Middle Name:
ASIF
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
407-843-0443

Provider Taxonomy Codes

  • Taxonomy code: 207RG0100X , with the licence number:  ME79526 , 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: 262273400 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 005769000 . 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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