Healthcare Provider Details

I. General information

NPI: 1811993355
Provider Name (Legal Business Name): SUSHAMA VAZRALA M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/21/2005
Last Update Date: 09/15/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1609 PASADENA AVE S SUITE 3A
SOUTH PASADENA FL
33707-4565
US

IV. Provider business mailing address

10000 BAY PINES BLVD, BUILDING 101
BAY PINES FL
33744-8200
US

V. Phone/Fax

Practice location:
  • Phone: 727-345-5700
  • Fax: 727-345-5755
Mailing address:
  • Phone: 727-398-6661
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberME88785
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: