=====================================================
General NPI Number Information
=====================================================
NPI Number | 1710450267
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BETHESDA MEDICAL CLINIC, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/08/2019
-----------------------------------------------------
Last Update Date | 10/21/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11050 GRIFFIN RD STE 104
-----------------------------------------------------
City | DAVIE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33328-3227
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-824-1922
-----------------------------------------------------
Fax | 954-824-1922
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11050 GRIFFIN RD STE 104
-----------------------------------------------------
City | DAVIE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33328-3227
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-824-1922
-----------------------------------------------------
Fax | 504-309-4193
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEDICAL DIRECTOR
-----------------------------------------------------
Name | DR. SHIBU VARUGHESE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 504-265-8304
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RH0003X
-----------------------------------------------------
Taxonomy Name | Hematology & Oncology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207RG0300X
-----------------------------------------------------
Taxonomy Name | Geriatric Medicine (Internal Medicine) Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207RE0101X
-----------------------------------------------------
Taxonomy Name | Endocrinology, Diabetes & Metabolism Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------