Provider Demographics
NPI:1972574333
Name:JATHAL, ADWAIT H (MD)
Entity Type:Individual
Prefix:
First Name:ADWAIT
Middle Name:H
Last Name:JATHAL
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 1:200 MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32901-3100
Mailing Address - Country:US
Mailing Address - Phone:321-952-0700
Mailing Address - Fax:321-952-4444
Practice Address - Street 1:200 MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-3100
Practice Address - Country:US
Practice Address - Phone:321-952-0700
Practice Address - Fax:321-952-4444
Is Sole Proprietor?:No
Enumeration Date:2006-02-01
Last Update Date:2015-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME96379207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1378963OtherAETNA
FL293711OtherWELLCARE
FL56422OtherBLUE CROSS BLUE SHIELD
FL276213700Medicaid
FL7863816OtherAETNA
FL2769681002OtherCIGNA
FL2769681002OtherCIGNA
FL276213700Medicaid