Provider Demographics
NPI:1386975910
Name:MID-FLORIDA PRIMARY CARE
Entity type:Organization
Organization Name:MID-FLORIDA PRIMARY CARE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RAVI
Authorized Official - Middle Name:P
Authorized Official - Last Name:GUPTA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:352-728-4242
Mailing Address - Street 1:401 NORTH BLVD W
Mailing Address - Street 2:
Mailing Address - City:LEESBURG
Mailing Address - State:FL
Mailing Address - Zip Code:34748-5044
Mailing Address - Country:US
Mailing Address - Phone:352-728-4242
Mailing Address - Fax:352-728-8030
Practice Address - Street 1:8525 US HIGHWAY 441
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:FL
Practice Address - Zip Code:34788-4021
Practice Address - Country:US
Practice Address - Phone:352-460-0922
Practice Address - Fax:352-398-4699
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MID-FLORIDA PRIMARY CARE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-01-21
Last Update Date:2010-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLHCC7913261QS1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS1200XAmbulatory Health Care FacilitiesClinic/CenterSleep Disorder Diagnostic
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK3761Medicare PIN