Healthcare Provider Details

I. General information

NPI: 1649340258
Provider Name (Legal Business Name): AJAY K GOYAL MD PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/09/2006
Last Update Date: 12/12/2025
Certification Date: 12/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2011 SOUTH 25TH STREET SUITE 106
FORT. PIERCE FL
34947-4795
US

IV. Provider business mailing address

2011 SOUTH 25TH STREET SUITE 106
FORT. PIERCE FL
34947-4795
US

V. Phone/Fax

Practice location:
  • Phone: 772-468-7020
  • Fax: 772-468-7698
Mailing address:
  • Phone: 772-468-7020
  • Fax: 772-468-7698

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberME74489
License Number StateFL

VIII. Authorized Official

Name: AJAY K GOYAL
Title or Position: PRESIDENT
Credential: MD
Phone: 772-468-7020