Provider Demographics
NPI:1952487787
Name:RATHINASAMY, PALANISAMY (MD)
Entity Type:Individual
Prefix:DR
First Name:PALANISAMY
Middle Name:
Last Name:RATHINASAMY
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 1:205 S.MOON AVE, SUITE 102
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33511-5716
Mailing Address - Country:US
Mailing Address - Phone:813-681-4644
Mailing Address - Fax:813-654-4486
Practice Address - Street 1:205 S.MOON AVE, SUITE 102
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-5716
Practice Address - Country:US
Practice Address - Phone:813-681-4644
Practice Address - Fax:813-654-4486
Is Sole Proprietor?:No
Enumeration Date:2006-10-27
Last Update Date:2011-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0046555208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
01110OtherUNIVERSAL
204455OtherAVMED
FL30840OtherBLUECROSS/BLUESHIELD
FL040231100Medicaid
020006402OtherR.R.MEDICARE
5796381OtherGHI
205115OtherAMERIGROUP
4111547OtherAETNA
0571459001OtherCIGNA HMO
204455OtherAVMED
FL040231100Medicaid