Healthcare Provider Details

I. General information

NPI: 1164956611
Provider Name (Legal Business Name): MIRA M LOTFALLA M.B.B.CH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/11/2017
Last Update Date: 05/29/2024
Certification Date: 05/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4500 SAN PABLO RD S
JACKSONVILLE FL
32224-1865
US

IV. Provider business mailing address

4500 SAN PABLO RD S
JACKSONVILLE FL
32224-1865
US

V. Phone/Fax

Practice location:
  • Phone: 904-953-2000
  • Fax:
Mailing address:
  • Phone: 904-953-2000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ZP0101X
TaxonomyAnatomic Pathology Physician
License Number28405
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code207ZP0101X
TaxonomyAnatomic Pathology Physician
License Number65883
License Number StateMN
# 3
Primary TaxonomyY
Taxonomy Code207ZP0101X
TaxonomyAnatomic Pathology Physician
License NumberME156755
License Number StateFL
# 4
Primary TaxonomyN
Taxonomy Code207ZP0101X
TaxonomyAnatomic Pathology Physician
License NumberD89548
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: