Provider Demographics
NPI:1326194713
Name:MARK A NAGRANI MD PA
Entity Type:Organization
Organization Name:MARK A NAGRANI MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:NAGRANI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:386-423-5500
Mailing Address - Street 1:612 PALMETTO ST
Mailing Address - Street 2:
Mailing Address - City:NEW SMYRNA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32168-7327
Mailing Address - Country:US
Mailing Address - Phone:386-423-5500
Mailing Address - Fax:386-409-9762
Practice Address - Street 1:612 PALMETTO ST
Practice Address - Street 2:
Practice Address - City:NEW SMYRNA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32168-7327
Practice Address - Country:US
Practice Address - Phone:386-423-5500
Practice Address - Fax:386-409-9762
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-26
Last Update Date:2013-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME48245174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK2958Medicare ID - Type UnspecifiedMEDICARE GROUP NUMBER
FLX23678Medicare UPIN