Healthcare Provider Details

I. General information

NPI: 1689661217
Provider Name (Legal Business Name): DILEEP RAJHAVENDRA YAVAGAL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/29/2005
Last Update Date: 03/02/2023
Certification Date: 03/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1150 NW 14TH ST STE 609
MIAMI FL
33136-2117
US

IV. Provider business mailing address

1120 NW 14TH ST FL 13
MIAMI FL
33136-2107
US

V. Phone/Fax

Practice location:
  • Phone: 305-355-1103
  • Fax: 305-355-1102
Mailing address:
  • Phone: 305-355-1103
  • Fax: 305-355-1102

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084V0102X
TaxonomyVascular Neurology Physician
License NumberME100624
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License NumberME100624
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: