=====================================================
General NPI Number Information
=====================================================
NPI Number | 1932362787
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MUKUL GARG MD PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/02/2008
-----------------------------------------------------
Last Update Date | 09/08/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 875 STERTHAUS AVE
-----------------------------------------------------
City | ORMOND BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32174-5131
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 386-676-6000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1917
-----------------------------------------------------
City | ORMOND BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32175-1917
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 386-676-4419
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MD PA
-----------------------------------------------------
Name | MUKUL GARG
-----------------------------------------------------
Credential | MD PA
-----------------------------------------------------
Telephone | 386-676-4419
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | ME 0047738
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------