Provider Demographics
NPI:1598827479
Name:MID FLORIDA PRIMARY CARE PA
Entity type:Organization
Organization Name:MID FLORIDA PRIMARY CARE PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
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:352-728-4868
Practice Address - Street 1:401 NORTH BLVD W
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:FL
Practice Address - Zip Code:34748-5044
Practice Address - Country:US
Practice Address - Phone:352-728-4242
Practice Address - Fax:352-728-4868
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-15
Last Update Date:2013-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME71724207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK3761Medicare PIN