Healthcare Provider Details

I. General information

NPI: 1770724130
Provider Name (Legal Business Name): WEST FLORIDA MEDICAL ASSOCIATES, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/16/2009
Last Update Date: 09/08/2021
Certification Date: 09/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

213 S PINE AVE
INVERNESS FL
34452-4830
US

IV. Provider business mailing address

3404 N LECANTO HWY STE C
BEVERLY HILLS FL
34465-3569
US

V. Phone/Fax

Practice location:
  • Phone: 352-560-3000
  • Fax: 352-419-6513
Mailing address:
  • Phone: 352-746-1558
  • Fax: 352-746-3838

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberME100419
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberME69230
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9102858
License Number StateFL

VIII. Authorized Official

Name: DR. HASIBUL H KHAN
Title or Position: PHYSICAN
Credential: M.D.
Phone: 352-560-3000