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General NPI Number Information
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NPI Number | 1164956611
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Entity Type | Individual
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Provider Name | MIRA M LOTFALLA M.B.B.CH
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Gender | Female
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Dates
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Enumeration Date | 04/11/2017
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Last Update Date | 05/29/2024
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Provider Practice Location Address
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Address Line | 4500 SAN PABLO RD S
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City | JACKSONVILLE
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State | FL
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Zip | 32224-1865
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Country | US
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Telephone | 904-953-2000
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Fax |
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Provider Business Mailing Address
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Address Line | 4500 SAN PABLO RD S
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City | JACKSONVILLE
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State | FL
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Zip | 32224-1865
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Country | US
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Telephone | 904-953-2000
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207ZP0101X
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Taxonomy Name | Anatomic Pathology Physician
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License Number | 28405
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License Number State | MN
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Taxonomy #2
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Taxonomy Code | 207ZP0101X
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Taxonomy Name | Anatomic Pathology Physician
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License Number | 65883
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License Number State | MN
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Taxonomy #3
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Taxonomy Code | 207ZP0101X
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Taxonomy Name | Anatomic Pathology Physician
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License Number | ME156755
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License Number State | FL
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Taxonomy #4
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Taxonomy Code | 207ZP0101X
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Taxonomy Name | Anatomic Pathology Physician
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License Number | D89548
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License Number State | MD
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