Provider Demographics
NPI:1942317516
Name:MEDIDI, SUBHAKARARAO (MD)
Entity Type:Individual
Prefix:
First Name:SUBHAKARARAO
Middle Name:
Last Name:MEDIDI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13110 ELK MOUNTAIN DR
Mailing Address - Street 2:SUNCOAST COMMUNITY HEALTH CENTERS INC
Mailing Address - City:RIVERVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:33579-7182
Mailing Address - Country:US
Mailing Address - Phone:813-349-7562
Mailing Address - Fax:813-349-7561
Practice Address - Street 1:14254 STATE ROAD 574
Practice Address - Street 2:TOM LEE COMMUNITY HEALTH CENTER
Practice Address - City:DOVER
Practice Address - State:FL
Practice Address - Zip Code:33527-4312
Practice Address - Country:US
Practice Address - Phone:813-349-7700
Practice Address - Fax:813-349-7761
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2011-11-23
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLME48578207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL373811600Medicaid
FL373811600Medicaid
FL61542Medicare ID - Type UnspecifiedMEDICARE