Provider Demographics
NPI:1265489108
Name:PERSAUD, PITAMBER (MD)
Entity Type:Individual
Prefix:DR
First Name:PITAMBER
Middle Name:
Last Name:PERSAUD
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 1:206 N FLORIDA AVE
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33801-4902
Mailing Address - Country:US
Mailing Address - Phone:863-209-7003
Mailing Address - Fax:863-274-3520
Practice Address - Street 1:206 N FLORIDA AVE
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33801-4902
Practice Address - Country:US
Practice Address - Phone:863-209-7003
Practice Address - Fax:863-274-3520
Is Sole Proprietor?:No
Enumeration Date:2006-05-27
Last Update Date:2023-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME156688207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036103193Medicaid
ILG14722Medicare UPIN
IL036103193Medicaid
ILK24151Medicare PIN