Provider Demographics
NPI:1093752826
Name:KUTHIALA, SEJAL S (MD)
Entity Type:Individual
Prefix:DR
First Name:SEJAL
Middle Name:S
Last Name:KUTHIALA
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 1:7015 AC SKINNER PARKWAY
Mailing Address - Street 2:SUITE 1
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32256
Mailing Address - Country:US
Mailing Address - Phone:904-363-2113
Mailing Address - Fax:904-538-3672
Practice Address - Street 1:5742 BOOTH RD
Practice Address - Street 2:SUITE A
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32207-5982
Practice Address - Country:US
Practice Address - Phone:904-739-7779
Practice Address - Fax:904-739-7771
Is Sole Proprietor?:No
Enumeration Date:2006-06-01
Last Update Date:2013-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 95618207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL302505OtherAVMED
FL7691884OtherAETNA
FL275155100Medicaid
GA705046969AMedicaid
FL42026OtherBCBS
FLU8734XMedicare PIN
FL7691884OtherAETNA
FLU8734YMedicare PIN
GA705046969AMedicaid
FLU8734WMedicare PIN
FL275155100Medicaid