Provider Demographics
NPI:1497717797
Name:ZALA, PRAVINCHANDRA (MD)
Entity Type:Individual
Prefix:DR
First Name:PRAVINCHANDRA
Middle Name:
Last Name:ZALA
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 1:500 VONDERBURG DR
Mailing Address - Street 2:STE 314 WEST
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33511-5978
Mailing Address - Country:US
Mailing Address - Phone:813-654-7030
Mailing Address - Fax:813-643-8298
Practice Address - Street 1:500 VONDERBURG DR
Practice Address - Street 2:STE 314 WEST
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-5964
Practice Address - Country:US
Practice Address - Phone:813-654-7030
Practice Address - Fax:813-643-8298
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-04
Last Update Date:2013-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME00621002084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL373592300Medicaid
F67585Medicare UPIN
23355Medicare ID - Type Unspecified