Healthcare Provider Details

I. General information

NPI: 1205024254
Provider Name (Legal Business Name): KIRANMAYI PALLA MUDDASANI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2007
Last Update Date: 07/20/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4306 ALTON RD
MIAMI BEACH FL
33140-2840
US

IV. Provider business mailing address

1715 CALAIS DR
MIAMI BEACH FL
33141-3510
US

V. Phone/Fax

Practice location:
  • Phone: 305-674-2121
  • Fax:
Mailing address:
  • Phone: 203-843-7761
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208C00000X
TaxonomyColon & Rectal Surgery Physician
License NumberME 124298
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: