Provider Demographics
NPI:1831436005
Name:MAHESH BHAMBORE MD PA
Entity type:Organization
Organization Name:MAHESH BHAMBORE MD PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MAHESH
Authorized Official - Middle Name:
Authorized Official - Last Name:BHAMBORE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:727-403-4573
Mailing Address - Street 1:20016 RYMAN PL
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33647-3452
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:21762 STATE ROAD 54
Practice Address - Street 2:
Practice Address - City:LUTZ
Practice Address - State:FL
Practice Address - Zip Code:33549-6921
Practice Address - Country:US
Practice Address - Phone:727-403-4573
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-08
Last Update Date:2013-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME100193207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLP01173486OtherRR MCR
FLP01173486OtherRR MCR