Provider Demographics
NPI:1275223638
Name:SOUTHPARK FUNCTIONAL MEDICINE PLLC
Entity Type:Organization
Organization Name:SOUTHPARK FUNCTIONAL MEDICINE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:SARITA
Authorized Official - Middle Name:
Authorized Official - Last Name:MAHTANI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:704-560-3316
Mailing Address - Street 1:5950 FAIRVIEW RD STE 406
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28210-3113
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5950 FAIRVIEW RD STE 406
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28210-3113
Practice Address - Country:US
Practice Address - Phone:704-560-3316
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-05-10
Last Update Date:2023-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty