=====================================================
General NPI Number Information
=====================================================
NPI Number | 1699798074
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MOHAMMED G CHOUDHURY, MDPA.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/26/2006
-----------------------------------------------------
Last Update Date | 08/28/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 155 NW ENTERPRISE WAY
-----------------------------------------------------
City | LAKE CITY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32055-8837
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 386-755-9457
-----------------------------------------------------
Fax | 386-755-3369
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1804
-----------------------------------------------------
City | LAKE CITY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32056-1804
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 386-755-9457
-----------------------------------------------------
Fax | 386-755-3369
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | MOHAMMED G CHOUDHURY
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 386-755-9457
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | ME93282
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207RP1001X
-----------------------------------------------------
Taxonomy Name | Pulmonary Disease Physician
-----------------------------------------------------
License Number | ME0068711
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207RP1001X
-----------------------------------------------------
Taxonomy Name | Pulmonary Disease Physician
-----------------------------------------------------
License Number | ME93282
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | ME0068711
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------