Provider Demographics
NPI:1245417609
Name:RANJAN, PRABODH (MD)
Entity Type:Individual
Prefix:
First Name:PRABODH
Middle Name:
Last Name:RANJAN
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:PO BOX 44004
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32231-4004
Mailing Address - Country:US
Mailing Address - Phone:904-346-3649
Mailing Address - Fax:904-348-5627
Practice Address - Street 1:820 PRUDENTIAL DR STE 304
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32207-8205
Practice Address - Country:US
Practice Address - Phone:904-346-3649
Practice Address - Fax:904-348-5627
Is Sole Proprietor?:No
Enumeration Date:2008-01-29
Last Update Date:2015-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME99514207RN0300X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL2805138-00Medicaid
FLP00712859OtherMEDICARE RR
GA139901302AMedicaid
FLK1951AOtherBPC MCR GROUP NO.
FLAL038UMedicare PIN