Provider Demographics
NPI:1114952058
Name:MATCHA, MRINALINI EMMA (MD)
Entity Type:Individual
Prefix:DR
First Name:MRINALINI
Middle Name:EMMA
Last Name:MATCHA
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 1:14134 NEPHRON LANE
Mailing Address - Street 2:
Mailing Address - City:HUDSON
Mailing Address - State:FL
Mailing Address - Zip Code:34667
Mailing Address - Country:US
Mailing Address - Phone:727-863-5418
Mailing Address - Fax:727-869-8626
Practice Address - Street 1:1700 66TH STREET NORTH
Practice Address - Street 2:SUITE 302
Practice Address - City:ST. PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33701
Practice Address - Country:US
Practice Address - Phone:727-290-9899
Practice Address - Fax:727-290-9898
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2011-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME102947207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL000644800Medicaid
FLBM592ZMedicare PIN
4F764Medicare ID - Type Unspecified
FL000644800Medicaid