Provider Demographics
NPI:1336454339
Name:WEST FLORIDA MEDICAL ASSOCIATES, P. A
Entity Type:Organization
Organization Name:WEST FLORIDA MEDICAL ASSOCIATES, P. A
Other - Org Name:COMPREHENSIVE PRIMARY CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHYSICIAN/DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:HASIBUL
Authorized Official - Middle Name:H
Authorized Official - Last Name:KHAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:352-503-2011
Mailing Address - Street 1:3404 N. LECANTO HWY
Mailing Address - Street 2:SUITE C
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:FL
Mailing Address - Zip Code:34465
Mailing Address - Country:US
Mailing Address - Phone:352-746-1558
Mailing Address - Fax:352-746-3838
Practice Address - Street 1:4363 SOUTH SUNCOAST BLVD
Practice Address - Street 2:
Practice Address - City:HOMOSASSA SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:34446
Practice Address - Country:US
Practice Address - Phone:352-503-2011
Practice Address - Fax:352-503-6892
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WEST FLORIDA MEDICAL ASSOCIATES, P.A.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-08-13
Last Update Date:2013-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME69230261QR1300X
FLME100419261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL252639500Medicaid
FL378926800Medicaid
FL252639500Medicaid
FL21310Medicare PIN
FLG15127Medicare UPIN
FLAO990ZMedicare Oscar/Certification