Basic Information
Provider Information | |||||||||
NPI: | 1619998861 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MAHTANI | ||||||||
FirstName: | ROSHAN | ||||||||
MiddleName: | B | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | DARYANANI | ||||||||
OtherFirstName: | ROSHAN | ||||||||
OtherMiddleName: | B | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | M.D. | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 38135 MARKET SQUARE | ||||||||
Address2: |   | ||||||||
City: | ZEPHYRHILLS | ||||||||
State: | FL | ||||||||
PostalCode: | 33542 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8135284975 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 6830 GALL BLVD | ||||||||
Address2: |   | ||||||||
City: | ZEPHYRHILLS | ||||||||
State: | FL | ||||||||
PostalCode: | 335422503 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8137833118 | ||||||||
FaxNumber: | 8133555036 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/22/2006 | ||||||||
LastUpdateDate: | 08/30/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 08/30/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | ME92365 | FL | Y |   | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | P00225143 | 01 | FL | RR MEDICARE | OTHER | 272021300 | 05 | FL |   | MEDICAID |