Healthcare Provider Details

I. General information

NPI: 1467234088
Provider Name (Legal Business Name): MINA ESHAK RADY MEGALLY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/18/2023
Last Update Date: 07/28/2026
Certification Date: 07/28/2026
Deactivation Date: 08/28/2024
Reactivation Date: 07/27/2026

III. Provider practice location address

1425 6TH ST NW
WINTER HAVEN FL
33881-2365
US

IV. Provider business mailing address

3439 BUOY CIR
WINTER GARDEN FL
34787-9073
US

V. Phone/Fax

Practice location:
  • Phone: 863-509-4330
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN31923
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: