Healthcare Provider Details

I. General information

NPI: 1720392681
Provider Name (Legal Business Name): MAYURI RAJU VEGASANA M.D
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MAYURI RAJU KOSURI M.D

II. Dates (important events)

Enumeration Date: 08/03/2010
Last Update Date: 01/10/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1463 CANTON RD STE A
AKRON OH
44312-4022
US

IV. Provider business mailing address

1 PERKINS SQ
AKRON OH
44308-1063
US

V. Phone/Fax

Practice location:
  • Phone: 330-253-4931
  • Fax: 330-253-8619
Mailing address:
  • Phone: 330-253-4931
  • Fax: 330-253-8619

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number35.125763
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: