=====================================================
General NPI Number Information
=====================================================
NPI Number | 1326194713
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MARK A NAGRANI MD PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/26/2007
-----------------------------------------------------
Last Update Date | 04/16/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 612 PALMETTO ST
-----------------------------------------------------
City | NEW SMYRNA BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32168-7327
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 386-423-5500
-----------------------------------------------------
Fax | 386-409-9762
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 612 PALMETTO ST
-----------------------------------------------------
City | NEW SMYRNA BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32168-7327
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 386-423-5500
-----------------------------------------------------
Fax | 386-409-9762
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEDICAL DIRECTOR
-----------------------------------------------------
Name | DR. MARK NAGRANI
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 386-423-5500
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | ME48245
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------