Healthcare Provider Details

I. General information

NPI: 1073990727
Provider Name (Legal Business Name): GAURAV AHLUWALIA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/01/2015
Last Update Date: 08/14/2023
Certification Date: 08/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 PALMETTO ST
NEW SMYRNA BEACH FL
32168-7322
US

IV. Provider business mailing address

PO BOX 945921
ATLANTA GA
30394-5921
US

V. Phone/Fax

Practice location:
  • Phone: 386-206-5908
  • Fax:
Mailing address:
  • Phone: 386-231-4529
  • Fax: 386-672-9904

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number296053
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberME163253
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: