=====================================================
General NPI Number Information
=====================================================
NPI Number | 1881627875
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MUTTATHIL P RAVINDRA NATHAN MD PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/10/2006
-----------------------------------------------------
Last Update Date | 11/03/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 14540 CORTEZ BLVD SUITE 119
-----------------------------------------------------
City | BROOKSVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34613-6056
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 352-597-3353
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3069 ANDERSON SNOW RD # 219
-----------------------------------------------------
City | SPRING HILL
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34609-5202
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 352-597-3353
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MUTTATHIL P RAVINDRA NATHAN
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 352-597-3353
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RC0000X
-----------------------------------------------------
Taxonomy Name | Cardiovascular Disease Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------