Provider Demographics
NPI:1720246242
Name:MOHANTY, BIBHU DATTA (MD)
Entity Type:Individual
Prefix:DR
First Name:BIBHU
Middle Name:DATTA
Last Name:MOHANTY
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:PO BOX 917770
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32891-0001
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2 TAMPA GENERAL CIR FL CIRCLE5
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33606-3603
Practice Address - Country:US
Practice Address - Phone:813-259-0600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-30
Last Update Date:2021-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME133637207RI0011X, 207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLBNQZOOtherBLUE CROSS BLUE SHIELD
FL022162600Medicaid