Healthcare Provider Details

I. General information

NPI: 1629003579
Provider Name (Legal Business Name): AMUDHA MANI PERUMAL M.D
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/11/2006
Last Update Date: 01/26/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 ARAPAHO AVE
ST AUGUSTINE FL
32084-4258
US

IV. Provider business mailing address

140 HISTORIC BRICK LN
ST AUGUSTINE FL
32095-8020
US

V. Phone/Fax

Practice location:
  • Phone: 904-829-9919
  • Fax: 904-829-2617
Mailing address:
  • Phone: 904-829-9919
  • Fax: 904-829-2617

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License NumberME76693
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: