Provider Demographics
NPI:1053419036
Name:PROBAKARAN, JANSI (MD)
Entity type:Individual
Prefix:
First Name:JANSI
Middle Name:
Last Name:PROBAKARAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5050 MASON CORBIN CT
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33907
Mailing Address - Country:US
Mailing Address - Phone:239-275-6678
Mailing Address - Fax:239-275-1785
Practice Address - Street 1:5050 MASON CORBIN CT
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33907
Practice Address - Country:US
Practice Address - Phone:239-275-6678
Practice Address - Fax:239-275-1785
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0046551207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL43792100Medicaid
D54508Medicare UPIN
FL364052Medicare ID - Type Unspecified