Basic Information
| Provider Information | |||||||||
| NPI: | 1720275233 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TIBREWALA | ||||||||
| FirstName: | AMIT | ||||||||
| MiddleName: | V. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 873 BRIGHTWATER CIR | ||||||||
| Address2: | |||||||||
| City: | MAITLAND | ||||||||
| State: | FL | ||||||||
| PostalCode: | 327514233 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4072841914 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1505 NORTHSIDE FORSYTH DR | ||||||||
| Address2: | STE 3600 | ||||||||
| City: | CUMMING | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30041 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7703438565 | ||||||||
| FaxNumber: | 7707813559 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/28/2007 | ||||||||
| LastUpdateDate: | 12/15/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/15/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | ME 108835 | FL | N | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207RC0000X | 068325 | GA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 003125698L | 05 | GA | MEDICAID | 003125698M | 05 | GA | MEDICAID | 003125698D | 05 | GA | MEDICAID | 003125698N | 05 | GA | MEDICAID |