Provider Demographics
NPI:1497789721
Name:MEHROTRA, BADRI NATH (MD PA)
Entity Type:Individual
Prefix:DR
First Name:BADRI
Middle Name:NATH
Last Name:MEHROTRA
Suffix:
Gender:M
Credentials:MD PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 HEALTH PARK BLVD
Mailing Address - Street 2:SUITE 216
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 216
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
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-11
Last Update Date:2010-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0021344174400000X, 207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL494005OtherAETNA-SPECIALTY
FL052939700Medicaid
FL494005OtherAETNA-SPECIALTY
FLD56706Medicare UPIN
FL112072951Medicare PIN