Provider Demographics
NPI:1588855431
Name:PRADEEP MATHUR, M.D., P.A.
Entity Type:Organization
Organization Name:PRADEEP MATHUR, M.D., P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PRADEEP
Authorized Official - Middle Name:
Authorized Official - Last Name:MATHUR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:386-775-7001
Mailing Address - Street 1:999 S VOLUSIA AVE
Mailing Address - Street 2:
Mailing Address - City:ORANGE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32763-6564
Mailing Address - Country:US
Mailing Address - Phone:386-775-7001
Mailing Address - Fax:386-774-2561
Practice Address - Street 1:999 S VOLUSIA AVE
Practice Address - Street 2:
Practice Address - City:ORANGE CITY
Practice Address - State:FL
Practice Address - Zip Code:32763-6564
Practice Address - Country:US
Practice Address - Phone:386-775-7001
Practice Address - Fax:386-774-2561
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-06
Last Update Date:2007-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME38056207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
K1185Medicare PIN