Provider Demographics
NPI:1942335104
Name:BROOKSVILLE WALK IN CLINIC LLC
Entity Type:Organization
Organization Name:BROOKSVILLE WALK IN CLINIC LLC
Other - Org Name:CENTRAL WALK IN CLINIC INC
Other - Org Type:Other Name
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:GAURAV
Authorized Official - Middle Name:
Authorized Official - Last Name:MALHOTRA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:352-684-3300
Mailing Address - Street 1:433 W JEFFERSON ST
Mailing Address - Street 2:
Mailing Address - City:BROOKSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:34601-2500
Mailing Address - Country:US
Mailing Address - Phone:352-796-7171
Mailing Address - Fax:352-796-1020
Practice Address - Street 1:433 W JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:BROOKSVILLE
Practice Address - State:FL
Practice Address - Zip Code:34601-2500
Practice Address - Country:US
Practice Address - Phone:352-796-7171
Practice Address - Fax:352-796-1020
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-21
Last Update Date:2012-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME93291207Q00000X
FLME0076833207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLG85638Medicare UPIN