Healthcare Provider Details

I. General information

NPI: 1164846986
Provider Name (Legal Business Name): DEREK PRABHARASUTH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/13/2014
Last Update Date: 09/11/2026
Certification Date: 09/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 N FLAMINGO RD STE 401
PEMBROKE PINES FL
33028-1011
US

IV. Provider business mailing address

2900 CORPORATE WAY # D
MIRAMAR FL
33025-3925
US

V. Phone/Fax

Practice location:
  • Phone: 305-682-2580
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License NumberME122730
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number60 255424
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number74307
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: