Healthcare Provider Details

I. General information

NPI: 1770688434
Provider Name (Legal Business Name): KANTILAL BHALANI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/14/2006
Last Update Date: 11/01/2022
Certification Date: 11/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1663 GEORGIA ST NE STE 400
PALM BAY FL
32907-2537
US

IV. Provider business mailing address

1663 GEORGIA ST NE STE 500
PALM BAY FL
32907-2589
US

V. Phone/Fax

Practice location:
  • Phone: 321-802-9080
  • Fax: 321-802-5211
Mailing address:
  • Phone: 321-802-9080
  • Fax: 321-802-5211

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberME39710
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License NumberME39710
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberME39710
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: