Provider Demographics
NPI:1790176766
Name:ANITA MATHUR MD
Entity Type:Organization
Organization Name:ANITA MATHUR MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LYNETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:TARNOWSKI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:386-774-7337
Mailing Address - Street 1:999 S VOLUSIA AVE STE B
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:386-774-7337
Mailing Address - Fax:
Practice Address - Street 1:999 S VOLUSIA AVE STE B
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:386-774-7337
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-12
Last Update Date:2015-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME67495208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
37584OtherBCBS
FL379425300Medicaid