Basic Information
Provider Information | |||||||||
NPI: | 1649488099 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MOUDGILL | ||||||||
FirstName: | NEIL | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 917770 | ||||||||
Address2: |   | ||||||||
City: | ORLANDO | ||||||||
State: | FL | ||||||||
PostalCode: | 328917770 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: |   | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 2 TAMPA GENERAL CIR | ||||||||
Address2: | STC 3RD FLOOR | ||||||||
City: | TAMPA | ||||||||
State: | FL | ||||||||
PostalCode: | 336063603 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8132590956 | ||||||||
FaxNumber: | 8132590606 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/18/2007 | ||||||||
LastUpdateDate: | 03/05/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | MD431182 | PA | N |   | Allopathic & Osteopathic Physicians | Surgery |   | 2086S0129X | ME114031 | FL | Y |   | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery |
ID Information
ID | Type | State | Issuer | Description | 14N1U | 01 | FL | BLUE CROSS BLUE SHIELD | OTHER | 007868400 | 05 | FL |   | MEDICAID |