Healthcare Provider Details

I. General information

NPI: 1932194420
Provider Name (Legal Business Name): SUBHASH KUMAR THAREJA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/12/2005
Last Update Date: 02/15/2023
Certification Date: 02/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

675 S BABCOCK ST
MELBOURNE FL
32901-1459
US

IV. Provider business mailing address

675 S BABCOCK ST
MELBOURNE FL
32901-1459
US

V. Phone/Fax

Practice location:
  • Phone: 321-951-1010
  • Fax: 321-952-4038
Mailing address:
  • Phone: 321-951-1010
  • Fax: 321-952-4038

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberME59791
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: