Healthcare Provider Details

I. General information

NPI: 1205897667
Provider Name (Legal Business Name): FLORIDAMEDCARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/28/2006
Last Update Date: 10/27/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1576 SE PORT ST LUCIE BLVD
PORT ST LUCIE FL
34952-5450
US

IV. Provider business mailing address

1576 SE PORT ST LUCIE BLVD
PORT ST LUCIE FL
34952-5450
US

V. Phone/Fax

Practice location:
  • Phone: 772-337-4578
  • Fax:
Mailing address:
  • Phone: 772-337-4578
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberME39359
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License NumberME30367
License Number StateFL

VIII. Authorized Official

Name: DR. MANJULA NAYYAR
Title or Position: PHYSICIAN
Credential: M.D.
Phone: 772-342-6911