Healthcare Provider Details

I. General information

NPI: 1619084761
Provider Name (Legal Business Name): GIRISH VASANT GHADE M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/24/2006
Last Update Date: 05/04/2026
Certification Date: 05/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 DEERFIELD PRESERVE BLVD
SAINT AUGUSTINE FL
32086-5966
US

IV. Provider business mailing address

PO BOX 730096
ORMOND BEACH FL
32173-0096
US

V. Phone/Fax

Practice location:
  • Phone: 386-871-0829
  • Fax:
Mailing address:
  • Phone: 386-506-8910
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberME 107681
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number01060057A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: