Provider Demographics
NPI:1124188180
Name:ALLAM, MAHESH GANDHI (MD)
Entity Type:Individual
Prefix:DR
First Name:MAHESH
Middle Name:GANDHI
Last Name:ALLAM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1110 DRUID CIR
Mailing Address - Street 2:
Mailing Address - City:LAKE WALES
Mailing Address - State:FL
Mailing Address - Zip Code:33853-4307
Mailing Address - Country:US
Mailing Address - Phone:863-877-2411
Mailing Address - Fax:863-354-6617
Practice Address - Street 1:1110 DRUID CIR
Practice Address - Street 2:
Practice Address - City:LAKE WALES
Practice Address - State:FL
Practice Address - Zip Code:33853-4307
Practice Address - Country:US
Practice Address - Phone:863-877-2411
Practice Address - Fax:863-354-6617
Is Sole Proprietor?:No
Enumeration Date:2006-12-11
Last Update Date:2015-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME64990207RP1001X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL4805299OtherUNITEDHEALTHCARE
FL593202432OtherGREATWEST
FL593202432OtherSOUTHCARE
FL593202432OtherFIRST HEALTH
FL110150086OtherMEDICARE RAILROAD
FL239982OtherAVMED
FL593202432OtherANCHOR
FL373685700Medicaid
FL593202432OtherAETNA
FL6452115002OtherCIGNA
FL593202432OtherBEECHSTREET
FL2000262OtherFIRST SERVICE ADMINISTRAT
FL23488OtherBCBS OF FL
FL593202432OtherCCN ONE SOURCE
FL593202432OtherBCE EMERGIS
FL593202432OtherPHCS
FL23488YMedicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER
FL373685700Medicaid