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General NPI Number Information
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NPI Number | 1841474103
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Entity Type | Organization
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Legal Business Name | MID-FLORIDA GASTROENTEROLOGY GROUP P A
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Dates
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Enumeration Date | 12/21/2007
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Last Update Date | 09/20/2010
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Provider Practice Location Address
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Address Line | 311 N MANGOUSTINE AVE
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City | SANFORD
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State | FL
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Zip | 32771-1098
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Country | US
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Telephone | 407-321-4570
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Fax | 407-321-7690
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Provider Business Mailing Address
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Address Line | 311 N MANGOUSTINE AVE
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City | SANFORD
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State | FL
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Zip | 32771-1098
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Country | US
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Telephone | 407-321-4570
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Fax | 407-321-7690
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. LENKALA REDDY MALLAIAH
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Credential | M.D.
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Telephone | 407-321-4570
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | ME0037029
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License Number State | FL
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