Basic Information
| Provider Information | |||||||||
| NPI: | 1649701731 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NANAVATI | ||||||||
| FirstName: | MRUGA | ||||||||
| MiddleName: | DIPTANSHU | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 100237 | ||||||||
| Address2: | |||||||||
| City: | GAINESVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 326103001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3522659522 | ||||||||
| FaxNumber: | 3522653575 | ||||||||
| Practice Location | |||||||||
| Address1: | 4420 LAKE BOONE TRL | ||||||||
| Address2: | |||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276077505 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9197843298 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/21/2017 | ||||||||
| LastUpdateDate: | 08/10/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/10/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 2022-01261 | NC | N | Allopathic & Osteopathic Physicians | Family Medicine | 207QH0002X | 2022-01261 | NC | N | Allopathic & Osteopathic Physicians | Family Medicine | Hospice and Palliative Medicine | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207QH0002X | A169463 | CA | Y | Allopathic & Osteopathic Physicians | Family Medicine | Hospice and Palliative Medicine |
No ID Information.