Provider Demographics
NPI:1457538837
Name:PUSHPA P NIRMUL MD PA
Entity type:Organization
Organization Name:PUSHPA P NIRMUL MD PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PUSHPA
Authorized Official - Middle Name:P
Authorized Official - Last Name:NIRMUL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:813-689-7571
Mailing Address - Street 1:602 VONDERBURG DR
Mailing Address - Street 2:SUITE 101
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33511-5900
Mailing Address - Country:US
Mailing Address - Phone:813-689-7571
Mailing Address - Fax:
Practice Address - Street 1:602 VONDERBURG DR
Practice Address - Street 2:SUITE 101
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-5900
Practice Address - Country:US
Practice Address - Phone:813-689-7571
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-28
Last Update Date:2011-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0038457208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL066482100Medicaid
FL280401800Medicaid