Basic Information
| Provider Information | |||||||||
| NPI: | 1093944928 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KHACHATUROVA | ||||||||
| FirstName: | INGA | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1900 DON WICKHAM DR | ||||||||
| Address2: | MP SL ADMIN | ||||||||
| City: | CLERMONT | ||||||||
| State: | FL | ||||||||
| PostalCode: | 347111979 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3525368840 | ||||||||
| FaxNumber: | 3525368841 | ||||||||
| Practice Location | |||||||||
| Address1: | 1900 DON WICKHAM DR | ||||||||
| Address2: | MP SL ADMIN | ||||||||
| City: | CLERMONT | ||||||||
| State: | FL | ||||||||
| PostalCode: | 347111979 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3525368840 | ||||||||
| FaxNumber: | 3525368841 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/13/2009 | ||||||||
| LastUpdateDate: | 11/15/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207RC0200X | ME119938 | FL | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine |
ID Information
| ID | Type | State | Issuer | Description | ME119938 | 01 | FL | MEDICAL LICENSE | OTHER | 012092000 | 05 | FL | MEDICAID |