Healthcare Provider Details

I. General information

NPI: 1053816918
Provider Name (Legal Business Name): MITRA ANOOSHEH KHOSRAVI FLANIGAN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MITRA ANOOSHEH KHOSRAVI MD

II. Dates (important events)

Enumeration Date: 03/23/2018
Last Update Date: 10/06/2026
Certification Date: 10/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 HEALTH PARK BLVD STE 5008
ST AUGUSTINE FL
32086-3705
US

IV. Provider business mailing address

PO BOX 44008
JACKSONVILLE FL
32231-4008
US

V. Phone/Fax

Practice location:
  • Phone: 904-819-2015
  • Fax: 904-819-4937
Mailing address:
  • Phone: 904-819-2015
  • Fax: 904-819-4937

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number65872
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number29294
License Number StateMN
# 3
Primary TaxonomyY
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License NumberME184485
License Number StateFL
# 4
Primary TaxonomyN
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License Number65872
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: