Healthcare Provider Details

I. General information

NPI: 1497789721
Provider Name (Legal Business Name): BADRI NATH MEHROTRA M.D. P.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/11/2006
Last Update Date: 10/27/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 HEALTH PARK BLVD SUITE 216
ST. AUGUSTINE FL
32086
US

IV. Provider business mailing address

301 HEALTH PARK BLVD SUITE 216
ST. AUGUSTINE FL
32086
US

V. Phone/Fax

Practice location:
  • Phone: 904-824-9044
  • Fax: 904-824-9055
Mailing address:
  • Phone: 904-824-9044
  • Fax: 904-824-9055

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License NumberME0021344
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License NumberME0021344
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: