Provider Demographics
NPI:1235205410
Name:SULTANA, MEHRUNNISA (MD)
Entity Type:Individual
Prefix:
First Name:MEHRUNNISA
Middle Name:
Last Name:SULTANA
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 1:2640 FOREST HILL BLVD
Mailing Address - Street 2:
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33406-5931
Mailing Address - Country:US
Mailing Address - Phone:561-616-8411
Mailing Address - Fax:561-616-8412
Practice Address - Street 1:2640 FOREST HILL BLVD
Practice Address - Street 2:
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33406-5931
Practice Address - Country:US
Practice Address - Phone:561-616-8411
Practice Address - Fax:561-616-8412
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-28
Last Update Date:2022-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME347972084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL100624400Medicaid
FLD55908Medicare UPIN
FL509382Medicare PIN