Provider Demographics
NPI:1689790487
Name:RATHAN, PRIYA (MD)
Entity Type:Individual
Prefix:
First Name:PRIYA
Middle Name:
Last Name:RATHAN
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 1:1002B S CHURCH AVE
Mailing Address - Street 2:#18601
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33679-9001
Mailing Address - Country:US
Mailing Address - Phone:813-395-0096
Mailing Address - Fax:
Practice Address - Street 1:14505 UNIVERSITY POINT PL
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33613-5424
Practice Address - Country:US
Practice Address - Phone:813-971-8500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-22
Last Update Date:2019-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME99930207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL002975800Medicaid
FL003249000Medicaid
FL002975800Medicaid
FL003249000Medicaid