Provider Demographics
NPI:1174511018
Name:MALHOTRA, SMITA (DPM)
Entity Type:Individual
Prefix:
First Name:SMITA
Middle Name:
Last Name:MALHOTRA
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 551380
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32255-1380
Mailing Address - Country:US
Mailing Address - Phone:904-285-9355
Mailing Address - Fax:904-285-7442
Practice Address - Street 1:1100 SAWGRASS VILLAGE DR
Practice Address - Street 2:STE 100
Practice Address - City:PONTE VEDRA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32082-5048
Practice Address - Country:US
Practice Address - Phone:904-285-9355
Practice Address - Fax:904-285-7442
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-13
Last Update Date:2015-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO3096213E00000X, 213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLV05062Medicare UPIN
U5471XMedicare UPIN
U5471XMedicare UPIN
5543590001Medicare NSC