Provider Demographics
NPI:1245265941
Name:TANDON, PRABHAT K (MD)
Entity type:Individual
Prefix:
First Name:PRABHAT
Middle Name:K
Last Name:TANDON
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 1:10250 SE 167TH PLACE RD UNIT 5
Mailing Address - Street 2:
Mailing Address - City:SUMMERFIELD
Mailing Address - State:FL
Mailing Address - Zip Code:34491-8682
Mailing Address - Country:US
Mailing Address - Phone:352-307-9925
Mailing Address - Fax:352-307-8442
Practice Address - Street 1:10250 SE 167TH PLACE RD
Practice Address - Street 2:SUITE 5-1
Practice Address - City:SUMMERFIELD
Practice Address - State:FL
Practice Address - Zip Code:34491-8686
Practice Address - Country:US
Practice Address - Phone:352-307-9925
Practice Address - Fax:342-307-8442
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2018-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD072463L207RE0101X
NJ25MA07690200207RE0101X
FLME118191207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL011902800Medicaid
FL14V9HOtherBCBS
PA001628134OtherHIGHMARK BS
PA080478Medicare PIN
PA001628134OtherHIGHMARK BS
FL14V9HOtherBCBS
NJ078435Medicare PIN