Provider Demographics
NPI:1003059270
Name:RAINA, NASRIN DATAR (MD)
Entity Type:Individual
Prefix:
First Name:NASRIN
Middle Name:DATAR
Last Name:RAINA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:151 PINE LAKE DR STE B
Mailing Address - Street 2:
Mailing Address - City:PONTE VEDRA
Mailing Address - State:FL
Mailing Address - Zip Code:32081-5136
Mailing Address - Country:US
Mailing Address - Phone:904-543-3677
Mailing Address - Fax:904-587-2586
Practice Address - Street 1:151 PINE LAKE DR STE B
Practice Address - Street 2:
Practice Address - City:PONTE VEDRA
Practice Address - State:FL
Practice Address - Zip Code:32081-5136
Practice Address - Country:US
Practice Address - Phone:904-543-3677
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-04-16
Last Update Date:2020-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME139724207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOP00964970OtherRAILROAD MEDICARE
MOP00964970OtherRAILROAD MEDICARE