Provider Demographics
NPI:1639241862
Name:PRIYANKA, GEETHA (MD)
Entity Type:Individual
Prefix:DR
First Name:GEETHA
Middle Name:
Last Name:PRIYANKA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:948 S WICKHAM RD
Mailing Address - Street 2:SUITE 103
Mailing Address - City:WEST MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32904-1647
Mailing Address - Country:US
Mailing Address - Phone:321-956-7370
Mailing Address - Fax:321-956-7873
Practice Address - Street 1:948 S WICKHAM RD
Practice Address - Street 2:SUITE 103
Practice Address - City:WEST MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32904-1647
Practice Address - Country:US
Practice Address - Phone:321-956-7370
Practice Address - Fax:321-956-7873
Is Sole Proprietor?:No
Enumeration Date:2006-11-14
Last Update Date:2015-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME78873207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL257471300Medicaid
FL49252OtherBCBS
FL257471300Medicaid
FL49252SMedicare PIN