Healthcare Provider Details

I. General information

NPI: 1114989415
Provider Name (Legal Business Name): SUPARNA A GULANI M.D
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/04/2006
Last Update Date: 10/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8075 GATE PKWY W SUITE 102
JACKSONVILLE FL
32216-3684
US

IV. Provider business mailing address

8075 GATE PKWY W SUITE 102
JACKSONVILLE FL
32216-3684
US

V. Phone/Fax

Practice location:
  • Phone: 904-296-1010
  • Fax: 904-296-0393
Mailing address:
  • Phone: 904-296-1010
  • Fax: 904-296-0393

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberME83942
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: