Provider Demographics
NPI:1740378009
Name:MID FLORIDA GASTROENTEROLOGY CONSULTANTS LLC
Entity type:Organization
Organization Name:MID FLORIDA GASTROENTEROLOGY CONSULTANTS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MOHAMMAD
Authorized Official - Middle Name:REZA
Authorized Official - Last Name:MASTALI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:407-822-1171
Mailing Address - Street 1:10000 W COLONIAL DR STE 389
Mailing Address - Street 2:
Mailing Address - City:OCOEE
Mailing Address - State:FL
Mailing Address - Zip Code:34761-3433
Mailing Address - Country:US
Mailing Address - Phone:407-822-1171
Mailing Address - Fax:407-822-1172
Practice Address - Street 1:10000 W COLONIAL DR STE 389
Practice Address - Street 2:
Practice Address - City:OCOEE
Practice Address - State:FL
Practice Address - Zip Code:34761-3433
Practice Address - Country:US
Practice Address - Phone:407-822-1171
Practice Address - Fax:407-822-1172
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-11
Last Update Date:2011-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1689762924OtherINDIVIDUAL NPI #
E8376YMedicare PIN
FL1689762924OtherINDIVIDUAL NPI #
FLG69636Medicare UPIN