| Sunstate Doctors Medical Group | |
|
5113 State Road 674, Ste 103 Wimauma FL 33598 | |
| (813) 633-2000 | |
| (813) 849-9301 |
| Full Name | Sunstate Doctors Medical Group |
|---|---|
| Speciality | Clinic/Center |
| Location | 5113 State Road 674, Ste 103, Wimauma, Florida |
| Authorized Official Name and Position | Khushi A. Dhaliwal (PRESIDENT) |
| Authorized Official Contact | 8136332000 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Sunstate Doctors Medical Group 5113 State Road 674, Ste 103 Wimauma FL 33598 Ph: (813) 633-2000 | Sunstate Doctors Medical Group 5113 State Road 674, Ste 103 Wimauma FL 33598 Ph: (813) 633-2000 |
| NPI Number | 1396000154 |
|---|---|
| Provider Enumeration Date | 07/09/2012 |
| Last Update Date | 04/20/2024 |
| Medicare PECOS PAC ID | 9537313093 |
|---|---|
| Medicare Enrollment ID | O20130208000287 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1396000154 | NPI | - | NPPES |
| 007662600 | Medicaid | FL |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 207Q00000X | Family Medicine | (* (Not Available)) | Secondary |
| 261QP2300X | Clinic/center - Primary Care | ME0059912 (Florida) | Primary |
| Provider Name | Barry P Nash |
|---|---|
| Provider Type | Practitioner - Internal Medicine |
| Provider Identifiers | NPI Number: 1659497303 PECOS PAC ID: 3476632472 Enrollment ID: I20080528000546 |
| Provider Name | Khushi Acushla Dhaliwal |
|---|---|
| Provider Type | Practitioner - Family Practice |
| Provider Identifiers | NPI Number: 1396988952 PECOS PAC ID: 4284883687 Enrollment ID: I20120928000254 |
| Provider Name | Jami Nicole Martinez-maldonado |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1568992089 PECOS PAC ID: 9830463363 Enrollment ID: I20170922001023 |
| Provider Name | Shemushi Nasreen |
|---|---|
| Provider Type | Practitioner - Family Practice |
| Provider Identifiers | NPI Number: 1366869687 PECOS PAC ID: 2769703966 Enrollment ID: I20180829003847 |
| Provider Name | Amy Kwok |
|---|---|
| Provider Type | Practitioner - Internal Medicine |
| Provider Identifiers | NPI Number: 1790135739 PECOS PAC ID: 3274827944 Enrollment ID: I20220906002232 |
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