Provider Demographics
NPI:1932362787
Name:MUKUL GARG MD PA
Entity Type:Organization
Organization Name:MUKUL GARG MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD PA
Authorized Official - Prefix:
Authorized Official - First Name:MUKUL
Authorized Official - Middle Name:
Authorized Official - Last Name:GARG
Authorized Official - Suffix:
Authorized Official - Credentials:MD PA
Authorized Official - Phone:386-676-4419
Mailing Address - Street 1:PO BOX 1917
Mailing Address - Street 2:
Mailing Address - City:ORMOND BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32175-1917
Mailing Address - Country:US
Mailing Address - Phone:386-676-4419
Mailing Address - Fax:
Practice Address - Street 1:875 STERTHAUS AVE
Practice Address - Street 2:
Practice Address - City:ORMOND BEACH
Practice Address - State:FL
Practice Address - Zip Code:32174-5131
Practice Address - Country:US
Practice Address - Phone:386-676-6000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-02
Last Update Date:2008-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 0047738174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL047843100Medicaid