Healthcare Provider Details

I. General information

NPI: 1952746273
Provider Name (Legal Business Name): KSHAMAYA PANCHAMUKHI MD PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/30/2013
Last Update Date: 04/30/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6039 COLLINS AVE 1711
MIAMI BEACH FL
33140-2203
US

IV. Provider business mailing address

6039 COLLINS AVE 1711
MIAMI BEACH FL
33140-2203
US

V. Phone/Fax

Practice location:
  • Phone: 305-202-3349
  • Fax:
Mailing address:
  • Phone: 305-202-3349
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberME105527
License Number StateFL

VIII. Authorized Official

Name: KSHAMAYA B PANCHAMUKHI
Title or Position: OFFICER
Credential: MD
Phone: 305-202-3349