Provider Demographics
NPI:1427253525
Name:RAVINDRA NATHAN, SUSHEELA (MD)
Entity type:Individual
Prefix:
First Name:SUSHEELA
Middle Name:
Last Name:RAVINDRA NATHAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5901 SW 74TH ST
Mailing Address - Street 2:SUITE 202
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33143-5165
Mailing Address - Country:US
Mailing Address - Phone:305-665-4614
Mailing Address - Fax:305-667-0239
Practice Address - Street 1:14555 CORTEZ BLVD
Practice Address - Street 2:
Practice Address - City:BROOKSVILLE
Practice Address - State:FL
Practice Address - Zip Code:34613-6003
Practice Address - Country:US
Practice Address - Phone:352-796-6000
Practice Address - Fax:305-667-0239
Is Sole Proprietor?:No
Enumeration Date:2007-06-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 270792080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLD85400Medicare UPIN