Provider Demographics
NPI:1710169826
Name:MINA B BHATT MD PA
Entity Type:Organization
Organization Name:MINA B BHATT MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MINA
Authorized Official - Middle Name:B
Authorized Official - Last Name:BHATT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:863-699-1181
Mailing Address - Street 1:103 TOMOKA BLVD S
Mailing Address - Street 2:
Mailing Address - City:LAKE PLACID
Mailing Address - State:FL
Mailing Address - Zip Code:33852-8123
Mailing Address - Country:US
Mailing Address - Phone:863-699-1181
Mailing Address - Fax:
Practice Address - Street 1:103 TOMOKA BLVD S
Practice Address - Street 2:
Practice Address - City:LAKE PLACID
Practice Address - State:FL
Practice Address - Zip Code:33852-8123
Practice Address - Country:US
Practice Address - Phone:863-699-1181
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-30
Last Update Date:2007-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0049354207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK6152Medicare PIN