Healthcare Provider Details

I. General information

NPI: 1134096027
Provider Name (Legal Business Name): LUCENT PHYSICIAN GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/23/2025
Last Update Date: 10/23/2025
Certification Date: 10/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2575 NORTHBROOKE PLAZA DR UNIT 207
NAPLES FL
34119-8099
US

IV. Provider business mailing address

2338 IMMOKALEE RD # 203
NAPLES FL
34110-1445
US

V. Phone/Fax

Practice location:
  • Phone: 239-919-4342
  • Fax: 239-919-4342
Mailing address:
  • Phone: 239-919-4342
  • Fax: 239-919-4342

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0206X
TaxonomyPediatric Gastroenterology Physician
License Number
License Number State

VIII. Authorized Official

Name: KINJAL SURYAWALA
Title or Position: OWNER
Credential: MD
Phone: 469-733-0196