Provider Demographics
NPI:1376193029
Name:DAYTONA BEACH NEPHROLOGY LLC
Entity Type:Organization
Organization Name:DAYTONA BEACH NEPHROLOGY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RAJDEEP
Authorized Official - Middle Name:SINGH
Authorized Official - Last Name:GADH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:386-304-8302
Mailing Address - Street 1:1728 DUNLAWTON AVE STE 4
Mailing Address - Street 2:
Mailing Address - City:PORT ORANGE
Mailing Address - State:FL
Mailing Address - Zip Code:32127-2923
Mailing Address - Country:US
Mailing Address - Phone:386-304-8302
Mailing Address - Fax:386-304-8204
Practice Address - Street 1:1728 DUNLAWTON AVE STE 4
Practice Address - Street 2:
Practice Address - City:PORT ORANGE
Practice Address - State:FL
Practice Address - Zip Code:32127-2923
Practice Address - Country:US
Practice Address - Phone:386-304-8302
Practice Address - Fax:386-304-8204
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-09-16
Last Update Date:2021-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL0001Medicaid