Healthcare Provider Details

I. General information

NPI: 1134450869
Provider Name (Legal Business Name): SURENDAR GAJENDRA RAO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/20/2010
Last Update Date: 10/20/2020
Certification Date: 10/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3345 BURNS RD STE 302
PALM BEACH GARDENS FL
33410-4321
US

IV. Provider business mailing address

14750 NW 77TH CT STE 100
MIAMI LAKES FL
33016-1507
US

V. Phone/Fax

Practice location:
  • Phone: 561-622-7661
  • Fax: 561-622-4651
Mailing address:
  • Phone: 786-758-3152
  • Fax: 786-441-2156

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberEP10034290
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number62640-20
License Number StateWI
# 3
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberACN702
License Number StateFL
# 4
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberME136965
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: