Provider Demographics
NPI:1902365778
Name:BASKARAN, PULIDEVAN
Entity Type:Individual
Prefix:DR
First Name:PULIDEVAN
Middle Name:
Last Name:BASKARAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1900 DON WICKHAM DR
Mailing Address - Street 2:
Mailing Address - City:CLERMONT
Mailing Address - State:FL
Mailing Address - Zip Code:34711-1979
Mailing Address - Country:US
Mailing Address - Phone:352-536-8840
Mailing Address - Fax:352-536-8841
Practice Address - Street 1:1900 DON WICKHAM DR
Practice Address - Street 2:
Practice Address - City:CLERMONT
Practice Address - State:FL
Practice Address - Zip Code:34711-1979
Practice Address - Country:US
Practice Address - Phone:352-536-8840
Practice Address - Fax:352-536-8841
Is Sole Proprietor?:No
Enumeration Date:2019-03-19
Last Update Date:2022-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
FLME155830207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL114550500Medicaid