Healthcare Provider Details

I. General information

NPI: 1790176766
Provider Name (Legal Business Name): ANITA MATHUR MD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/12/2015
Last Update Date: 02/12/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

999 S VOLUSIA AVE STE B
ORANGE CITY FL
32763-6564
US

IV. Provider business mailing address

999 S VOLUSIA AVE STE B
ORANGE CITY FL
32763-6564
US

V. Phone/Fax

Practice location:
  • Phone: 386-774-7337
  • Fax:
Mailing address:
  • Phone: 386-774-7337
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME67495
License Number StateFL

VIII. Authorized Official

Name: LYNETTE TARNOWSKI
Title or Position: BILLING MANAGER
Credential:
Phone: 386-774-7337