Provider Demographics
NPI:1932109782
Name:DESHMUKH, PRATIMA (MD)
Entity Type:Individual
Prefix:
First Name:PRATIMA
Middle Name:
Last Name:DESHMUKH
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 1:515 W STATE ROAD 434 STE 110
Mailing Address - Street 2:
Mailing Address - City:LONGWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:32750-5161
Mailing Address - Country:US
Mailing Address - Phone:407-830-8600
Mailing Address - Fax:407-830-5110
Practice Address - Street 1:515 W STATE ROAD 434
Practice Address - Street 2:
Practice Address - City:LONGWOOD
Practice Address - State:FL
Practice Address - Zip Code:32750-4981
Practice Address - Country:US
Practice Address - Phone:407-830-8600
Practice Address - Fax:407-830-5110
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-22
Last Update Date:2021-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME103241207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL023893100Medicaid
FLEN433YOtherMEDICARE
110D710810OtherBCBS
MIP10010002Medicare ID - Type Unspecified