MEDICARE: MANDARIN OB-GYN PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207V00000X	Obstetrics & Gynecology Physician	ME77915	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1407956972
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MANDARIN OB-GYN PA

Provider Business Mailing Address
First Line	:	13241 BARTRAM PARK BLVD UNIT 1309
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32258-5229
Country	:	US
Telephone Number	:	904-288-6910
Fax Number	:	904-288-6916

Provider Business Practice Location Address
First Line	:	13241 BARTRAM PARK BLVD UNIT 1309
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32258-5229
Country	:	US
Telephone Number	:	904-288-6910
Fax Number	:	904-288-6916

Authorized Official
Title or Position	:	PRESIDENT
Name	:	GHULAM QUADIR KHAN
Credential	:	MD
Telephone Number	:	904-288-6910

Provider Enumeration Date	:	09/25/2006
Last Update Date	:	01/05/2018

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