Provider Demographics
NPI:1720275233
Name:TIBREWALA, AMIT V (MD)
Entity Type:Individual
Prefix:
First Name:AMIT
Middle Name:V
Last Name:TIBREWALA
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 1:873 BRIGHTWATER CIR
Mailing Address - Street 2:
Mailing Address - City:MAITLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32751-4233
Mailing Address - Country:US
Mailing Address - Phone:407-284-1914
Mailing Address - Fax:
Practice Address - Street 1:1505 NORTHSIDE FORSYTH DR
Practice Address - Street 2:STE 3600
Practice Address - City:CUMMING
Practice Address - State:GA
Practice Address - Zip Code:30041
Practice Address - Country:US
Practice Address - Phone:770-343-8565
Practice Address - Fax:770-781-3559
Is Sole Proprietor?:No
Enumeration Date:2007-09-28
Last Update Date:2020-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 108835207RC0000X
GA068325207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003125698LMedicaid
GA003125698MMedicaid
GA003125698DMedicaid
GA003125698NMedicaid
GA202I111592Medicare PIN