Provider Demographics
NPI:1538488895
Name:PATTATHAN, MITHUN BEKAL (MD)
Entity Type:Individual
Prefix:
First Name:MITHUN
Middle Name:BEKAL
Last Name:PATTATHAN
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 1:7500 RIALTO BLVD STE 1-140
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78735-8534
Mailing Address - Country:US
Mailing Address - Phone:512-730-3056
Mailing Address - Fax:888-730-1925
Practice Address - Street 1:13681 DOCTORS WAY
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33912
Practice Address - Country:US
Practice Address - Phone:512-730-3056
Practice Address - Fax:888-730-1925
Is Sole Proprietor?:No
Enumeration Date:2010-05-26
Last Update Date:2019-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME117052208M00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLCH6711OtherRR MEDICARE GROUP
FL915448OtherWELLCARE
FLPO1567468OtherRR MEDICARE
FL0093962-00Medicaid
FL45681OtherBCBS GROUP
FL2610299-00OtherMEDICAID GROUP
FL45681OtherMEDICARE GROUP
FL371804OtherAVMED
FL45681OtherMEDICARE GROUP