Provider Demographics
NPI:1760440481
Name:RATHORE, SUMRA (MD)
Entity Type:Individual
Prefix:
First Name:SUMRA
Middle Name:
Last Name:RATHORE
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 1:5008 MUSTANG RD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-6028
Mailing Address - Country:US
Mailing Address - Phone:904-887-9780
Mailing Address - Fax:904-296-8467
Practice Address - Street 1:5008 MUSTANG RD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-6028
Practice Address - Country:US
Practice Address - Phone:904-296-2350
Practice Address - Fax:904-296-8467
Is Sole Proprietor?:No
Enumeration Date:2006-05-02
Last Update Date:2010-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 71280207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL220032664OtherRAILROAD MEDICARE
FL10047ZMedicare PIN