Healthcare Provider Details

I. General information

NPI: 1790969137
Provider Name (Legal Business Name): NAGAVARDHAN VASUKI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/20/2007
Last Update Date: 08/21/2025
Certification Date: 08/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8440 LAKE WORTH RD STE 100
WELLINGTON FL
33467
US

IV. Provider business mailing address

7593 W BOYNTON BEACH BLVD STE 220
BOYNTON BEACH FL
33437-6162
US

V. Phone/Fax

Practice location:
  • Phone: 561-967-5033
  • Fax:
Mailing address:
  • Phone: 561-966-7717
  • Fax: 888-316-2198

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberME108818
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number001522
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberLL31152
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: