Provider Demographics
NPI:1194945097
Name:RIZWANA THANAWALA MD PA
Entity type:Organization
Organization Name:RIZWANA THANAWALA MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RIZWANA
Authorized Official - Middle Name:
Authorized Official - Last Name:THANAWALA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:386-758-6094
Mailing Address - Street 1:4367 NW AMERICAN LANE
Mailing Address - Street 2:
Mailing Address - City:LAKE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32055-4828
Mailing Address - Country:US
Mailing Address - Phone:386-758-6094
Mailing Address - Fax:386-758-6995
Practice Address - Street 1:4367 NW AMERICAN LN
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:FL
Practice Address - Zip Code:32055-4828
Practice Address - Country:US
Practice Address - Phone:386-758-6094
Practice Address - Fax:386-758-6995
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-26
Last Update Date:2011-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL74502OtherBCBS GROUP ID
FL266910200Medicaid
FL266910200Medicaid