Basic Information
| Provider Information | |||||||||
| NPI: | 1467450080 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | AMIN | ||||||||
| FirstName: | SANJIV | ||||||||
| MiddleName: | PRAVIN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | |||||||||
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| OtherMiddleName: | |||||||||
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| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 34041 US HIGHWAY 19 N | ||||||||
| Address2: | SUITE A | ||||||||
| City: | PALM HARBOR | ||||||||
| State: | FL | ||||||||
| PostalCode: | 346842648 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7277860017 | ||||||||
| FaxNumber: | 7277867521 | ||||||||
| Practice Location | |||||||||
| Address1: | 34041 US HIGHWAY 19 N | ||||||||
| Address2: | SUITE A | ||||||||
| City: | PALM HARBOR | ||||||||
| State: | FL | ||||||||
| PostalCode: | 346842648 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7277860017 | ||||||||
| FaxNumber: | 7277867521 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/08/2005 | ||||||||
| LastUpdateDate: | 12/07/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | OS8939 | FL | Y | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 267419000 | 05 | FL | MEDICAID |