Provider Demographics
NPI:1417270091
Name:BADRI N MEHROTRA MD PA
Entity Type:Organization
Organization Name:BADRI N MEHROTRA MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:BADRI
Authorized Official - Middle Name:NATH
Authorized Official - Last Name:MEHROTRA
Authorized Official - Suffix:
Authorized Official - Credentials:MD, PA
Authorized Official - Phone:904-824-9044
Mailing Address - Street 1:301 HEALTH PARK BLVD
Mailing Address - Street 2:SUITE 219
Mailing Address - City:ST. AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32086
Mailing Address - Country:US
Mailing Address - Phone:904-824-9044
Mailing Address - Fax:904-824-9055
Practice Address - Street 1:301 HEALTH PARK BLVD
Practice Address - Street 2:SUITE 219
Practice Address - City:ST. AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32086
Practice Address - Country:US
Practice Address - Phone:904-824-9044
Practice Address - Fax:904-824-9055
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-10
Last Update Date:2010-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0021344207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
D56706Medicare UPIN
55049Medicare PIN