Healthcare Provider Details

I. General information

NPI: 1801157185
Provider Name (Legal Business Name): PRATIBHA LUMB M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/04/2012
Last Update Date: 08/25/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

630 N. MAIN STREET
WILLISTON FL
32696
US

IV. Provider business mailing address

23343 NW COUNTY ROAD 236
HIGH SPRINGS FL
32643-9669
US

V. Phone/Fax

Practice location:
  • Phone: 352-528-0587
  • Fax: 352-528-4834
Mailing address:
  • Phone: 386-454-0698
  • Fax: 386-454-0690

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberTRN#17328
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberME122011
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: