Healthcare Provider Details

I. General information

NPI: 1871911123
Provider Name (Legal Business Name): ANKUR KUMAR GOYAL M.D., MSC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/03/2014
Last Update Date: 07/17/2022
Certification Date: 07/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3030 HARDEN BLVD
LAKELAND FL
33803-7952
US

IV. Provider business mailing address

1324 LAKELAND HILLS BLVD. ATTN: MANAGED CARE DEPT
LAKELAND FL
33805
US

V. Phone/Fax

Practice location:
  • Phone: 863-687-1222
  • Fax: 863-603-6546
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number61452
License Number StateMN
# 3
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberME137355
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: