Provider Demographics
NPI:1699764910
Name:BASKAR, SUJATHA (MD)
Entity type:Individual
Prefix:
First Name:SUJATHA
Middle Name:
Last Name:BASKAR
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 1:1866 MAYO DR
Mailing Address - Street 2:
Mailing Address - City:TAVARES
Mailing Address - State:FL
Mailing Address - Zip Code:32778-4320
Mailing Address - Country:US
Mailing Address - Phone:352-508-5171
Mailing Address - Fax:352-508-5275
Practice Address - Street 1:1866 MAYO DR
Practice Address - Street 2:
Practice Address - City:TAVARES
Practice Address - State:FL
Practice Address - Zip Code:32778-4320
Practice Address - Country:US
Practice Address - Phone:352-508-5171
Practice Address - Fax:352-508-5275
Is Sole Proprietor?:No
Enumeration Date:2005-10-19
Last Update Date:2015-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME94000207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL27401500Medicaid
FL27401500Medicaid
FLU6482ZMedicare PIN