Healthcare Provider Details

I. General information

NPI: 1407191885
Provider Name (Legal Business Name): BRUNO SHANKAR SUBBARAO D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/11/2012
Last Update Date: 01/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7031 SW 62ND AVE
SOUTH MIAMI FL
33143-4701
US

IV. Provider business mailing address

533 NE 3RD AVE APT 505
FORT LAUDERDALE FL
33301-3283
US

V. Phone/Fax

Practice location:
  • Phone: 305-284-7500
  • Fax:
Mailing address:
  • Phone: 412-478-9148
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License NumberOS13628
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: