Provider Demographics
NPI:1447443403
Name:NIDRA LLC
Entity type:Organization
Organization Name:NIDRA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:RAHUL
Authorized Official - Middle Name:KUMAR
Authorized Official - Last Name:KAKKAR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:904-296-1300
Mailing Address - Street 1:6817 SOUTHPOINT PKWY
Mailing Address - Street 2:#802
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-6282
Mailing Address - Country:US
Mailing Address - Phone:904-296-1300
Mailing Address - Fax:904-239-3066
Practice Address - Street 1:9471 BAYMEADOWS ROAD
Practice Address - Street 2:SUITE 101
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32256
Practice Address - Country:US
Practice Address - Phone:904-296-1300
Practice Address - Fax:904-239-3066
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-23
Last Update Date:2013-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207R00000X, 207RC0200X, 207RP1001X, 207RS0012X
FLME79882261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care MedicineGroup - Multi-Specialty
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Multi-Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/CenterGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
H17914Medicare UPIN
AH804Medicare PIN