Provider Demographics
NPI:1407956972
Name:MANDARIN OB-GYN PA
Entity Type:Organization
Organization Name:MANDARIN OB-GYN PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GHULAM
Authorized Official - Middle Name:QUADIR
Authorized Official - Last Name:KHAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:904-288-6910
Mailing Address - Street 1:13241 BARTRAM PARK BLVD UNIT 1309
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32258-5229
Mailing Address - Country:US
Mailing Address - Phone:904-288-6910
Mailing Address - Fax:904-288-6916
Practice Address - Street 1:13241 BARTRAM PARK BLVD UNIT 1309
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32258-5229
Practice Address - Country:US
Practice Address - Phone:904-288-6910
Practice Address - Fax:904-288-6916
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-25
Last Update Date:2018-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME77915207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL256632000Medicaid
H00197Medicare UPIN