Healthcare Provider Details

I. General information

NPI: 1588615439
Provider Name (Legal Business Name): ROHAN ANIL DIAL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/15/2006
Last Update Date: 09/03/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1155 E 21ST ST
JACKSONVILLE FL
32206-2401
US

IV. Provider business mailing address

PO BOX 44008 UFJP PROVIDER ENROLLMENT
JACKSONVILLE FL
32231-4008
US

V. Phone/Fax

Practice location:
  • Phone: 904-359-9696
  • Fax:
Mailing address:
  • Phone: 904-244-3660
  • Fax: 904-244-3425

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME73857
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: