Healthcare Provider Details

I. General information

NPI: 1043982606
Provider Name (Legal Business Name): VIKRAMBEHERALLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/01/2021
Last Update Date: 04/04/2022
Certification Date: 04/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 OAK ST
GREEN COVE SPRINGS FL
32043-4317
US

IV. Provider business mailing address

84 WATERLINE DR
ST JOHNS FL
32259-2311
US

V. Phone/Fax

Practice location:
  • Phone: 904-284-9230
  • Fax:
Mailing address:
  • Phone: 212-767-9891
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: JUDY PAYNE
Title or Position: ADMIN
Credential:
Phone: 904-387-4778