Provider Demographics
NPI:1770724130
Name:WEST FLORIDA MEDICAL ASSOCIATES, PA
Entity type:Organization
Organization Name:WEST FLORIDA MEDICAL ASSOCIATES, PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHYSICAN
Authorized Official - Prefix:DR
Authorized Official - First Name:HASIBUL
Authorized Official - Middle Name:H
Authorized Official - Last Name:KHAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:352-560-3000
Mailing Address - Street 1:3404 N LECANTO HWY STE C
Mailing Address - Street 2:
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:FL
Mailing Address - Zip Code:34465-3569
Mailing Address - Country:US
Mailing Address - Phone:352-746-1558
Mailing Address - Fax:352-746-3838
Practice Address - Street 1:213 S PINE AVE
Practice Address - Street 2:
Practice Address - City:INVERNESS
Practice Address - State:FL
Practice Address - Zip Code:34452-4830
Practice Address - Country:US
Practice Address - Phone:352-560-3000
Practice Address - Fax:352-419-6513
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-16
Last Update Date:2021-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME69230207R00000X
FLPA9102858363A00000X
FLME100419207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL001124800Medicaid
FL00281900Medicaid
FL21310AMedicare PIN
FL103834Medicare PIN
FL21310Medicare PIN
FL27833WMedicare Oscar/Certification
FL001124800Medicaid
FLA0990ZMedicare PIN