Healthcare Provider Details

I. General information

NPI: 1609225689
Provider Name (Legal Business Name): KUSHAGRA SHRINATH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2016
Last Update Date: 06/16/2020
Certification Date: 06/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 N CLYDE MORRIS BLVD STE 200
DAYTONA BEACH FL
32114-2765
US

IV. Provider business mailing address

303 N CLYDE MORRIS BLVD
DAYTONA BEACH FL
32114-2709
US

V. Phone/Fax

Practice location:
  • Phone: 386-425-4165
  • Fax: 386-425-7545
Mailing address:
  • Phone: 386-425-4590
  • Fax: 386-226-4577

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberME140826
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: