Healthcare Provider Details

I. General information

NPI: 1720237290
Provider Name (Legal Business Name): MAYURA PRAKASH GUJARATHI M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/09/2008
Last Update Date: 10/19/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3100 SW 62ND AVE
MIAMI FL
33155
US

IV. Provider business mailing address

3530 SW 22ND ST APT 706
MIAMI FL
33145-3254
US

V. Phone/Fax

Practice location:
  • Phone: 786-624-3588
  • Fax:
Mailing address:
  • Phone: 313-405-3302
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number4301091793
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code2080P0204X
TaxonomyPediatric Emergency Medicine (Pediatrics) Physician
License NumberME 109789
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: