Healthcare Provider Details

I. General information

NPI: 1649701731
Provider Name (Legal Business Name): MRUGA NANAVATI MORRIS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MRUGA DIPTANSHU NANAVATI

II. Dates (important events)

Enumeration Date: 03/21/2017
Last Update Date: 06/22/2023
Certification Date: 06/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4420 LAKE BOONE TRL
RALEIGH NC
27607-7505
US

IV. Provider business mailing address

PO BOX 100237
GAINESVILLE FL
32610-3001
US

V. Phone/Fax

Practice location:
  • Phone: 919-784-3298
  • Fax:
Mailing address:
  • Phone: 352-265-9522
  • Fax: 352-265-3575

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2022-01261
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code207QH0002X
TaxonomyHospice and Palliative Medicine (Family Medicine) Physician
License Number2022-01261
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code207QH0002X
TaxonomyHospice and Palliative Medicine (Family Medicine) Physician
License NumberA169463
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: