Provider Demographics
NPI:1407902364
Name:MAZUMDER, MRIDUL K (MD)
Entity Type:Individual
Prefix:DR
First Name:MRIDUL
Middle Name:K
Last Name:MAZUMDER
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 1:1115 W CALL ST
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32304-3556
Mailing Address - Country:US
Mailing Address - Phone:850-431-5119
Mailing Address - Fax:850-431-2467
Practice Address - Street 1:1616 PHYSICIANS DR
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32308-4619
Practice Address - Country:US
Practice Address - Phone:850-431-5119
Practice Address - Fax:850-431-2467
Is Sole Proprietor?:No
Enumeration Date:2007-01-25
Last Update Date:2021-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME1295192084P0800X
SC272552084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC272555Medicaid
SCAA41153353Medicare UPIN