Provider Demographics
NPI:1922416643
Name:BHARTI SUNIL LALLA, MD FAAP
Entity Type:Organization
Organization Name:BHARTI SUNIL LALLA, MD FAAP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DEBBIE
Authorized Official - Middle Name:ELIZABETH
Authorized Official - Last Name:NAEGER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:239-561-2202
Mailing Address - Street 1:14171 METROPOLIS AVE
Mailing Address - Street 2:SUITE 202
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33912-4335
Mailing Address - Country:US
Mailing Address - Phone:239-561-2202
Mailing Address - Fax:239-561-3099
Practice Address - Street 1:14171 METROPOLIS AVE
Practice Address - Street 2:SUITE 202
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33912-4335
Practice Address - Country:US
Practice Address - Phone:239-561-2202
Practice Address - Fax:239-561-3099
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-25
Last Update Date:2014-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME061324208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL370593500Medicaid