=====================================================
General NPI Number Information
=====================================================
NPI Number | 1558570663
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GAITRI PERSAUD PTA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/22/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1191 E NEWPORT CENTER DR PENT HOUSE J
-----------------------------------------------------
City | DEERFIELD BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33442-7715
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-379-1066
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 403 NW 68TH AVE #505
-----------------------------------------------------
City | PLANTATION
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33317-7585
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-918-5344
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251K00000X
-----------------------------------------------------
Taxonomy Name | Public Health or Welfare Agency
-----------------------------------------------------
License Number | PTA20424
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------