Healthcare Provider Details

I. General information

NPI: 1376983536
Provider Name (Legal Business Name): SHANMUKHA SAI MUKTHAPURAM M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/02/2013
Last Update Date: 02/12/2024
Certification Date: 02/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10101 FOREST HILL BLVD
WELLINGTON FL
33414-6103
US

IV. Provider business mailing address

3180 S OCEAN DR APT 1408
HALLANDALE BEACH FL
33009-7252
US

V. Phone/Fax

Practice location:
  • Phone: 561-798-8500
  • Fax:
Mailing address:
  • Phone: 929-234-9843
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number35.128161
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License NumberME160215
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: