Healthcare Provider Details

I. General information

NPI: 1205278454
Provider Name (Legal Business Name): MEDICAL & PSYCHIATRIC INSITIUTE OF FLORIDA, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/29/2013
Last Update Date: 08/19/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6056 CENTRAL PARK BLVD
PORT ORANGE FL
32127-9539
US

IV. Provider business mailing address

927 BEVILLE RD STE 7
SOUTH DAYTONA FL
32119-1769
US

V. Phone/Fax

Practice location:
  • Phone: 304-216-4000
  • Fax: 386-676-2555
Mailing address:
  • Phone: 386-269-9009
  • Fax: 386-269-9004

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084F0202X
TaxonomyForensic Psychiatry Physician
License NumberME114528
License Number StateFL

VIII. Authorized Official

Name: ASAD KHAN
Title or Position: OWNER
Credential: MD
Phone: 304-216-4000