Healthcare Provider Details

I. General information

NPI: 1114975596
Provider Name (Legal Business Name): SURYA PRAKASH RAO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/05/2006
Last Update Date: 01/12/2021
Certification Date: 01/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1404 S RIDGEWOOD AVE
EDGEWATER FL
32132-2720
US

IV. Provider business mailing address

695 N CLYDE MORRIS BLVD
DAYTONA BEACH FL
32114-2321
US

V. Phone/Fax

Practice location:
  • Phone: 386-258-8722
  • Fax: 386-265-5928
Mailing address:
  • Phone: 386-258-8722
  • Fax: 386-258-9443

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207UN0901X
TaxonomyNuclear Cardiology Physician
License NumberME96830
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberME96830
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: