Provider Demographics
NPI:1215957741
Name:REGENCY ENDOCRINOLOGY, DIABETES AND METABOLISM, INC.
Entity type:Organization
Organization Name:REGENCY ENDOCRINOLOGY, DIABETES AND METABOLISM, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:MAHA
Authorized Official - Middle Name:F
Authorized Official - Last Name:ANSARA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:407-333-1212
Mailing Address - Street 1:752 STIRLING CENTER PL
Mailing Address - Street 2:SUITE 1008
Mailing Address - City:LAKE MARY
Mailing Address - State:FL
Mailing Address - Zip Code:32746-4889
Mailing Address - Country:US
Mailing Address - Phone:407-333-1212
Mailing Address - Fax:407-333-1213
Practice Address - Street 1:752 STIRLING CENTER PL
Practice Address - Street 2:SUITE 1008
Practice Address - City:LAKE MARY
Practice Address - State:FL
Practice Address - Zip Code:32746-4889
Practice Address - Country:US
Practice Address - Phone:407-333-1212
Practice Address - Fax:407-333-1213
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-20
Last Update Date:2013-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL0075530207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL74739OtherBCBS OF FLORIDA GROUP ID#
FL270616400Medicaid
FL74739OtherBCBS OF FLORIDA GROUP ID#