Provider Demographics
NPI:1063683126
Name:SUNSHINE STATE MEDICAL CLINIC PA
Entity Type:Organization
Organization Name:SUNSHINE STATE MEDICAL CLINIC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:UDAY
Authorized Official - Middle Name:SHANKER
Authorized Official - Last Name:MISHRA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:352-369-5440
Mailing Address - Street 1:1305 SE 25TH LOOP SUIT 103
Mailing Address - Street 2:
Mailing Address - City:OCALA
Mailing Address - State:FL
Mailing Address - Zip Code:34471
Mailing Address - Country:US
Mailing Address - Phone:352-369-5440
Mailing Address - Fax:352-369-5442
Practice Address - Street 1:1305 SE 25TH LOOP STE 103
Practice Address - Street 2:
Practice Address - City:OCALA
Practice Address - State:FL
Practice Address - Zip Code:34471-6090
Practice Address - Country:US
Practice Address - Phone:352-369-5440
Practice Address - Fax:352-369-5442
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-17
Last Update Date:2008-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME73537207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL45402Medicare PIN
FLG61117Medicare UPIN