Provider Demographics
NPI:1164846986
Name:PRABHARASUTH, DEREK (MD)
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:
Last Name:PRABHARASUTH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11760 SW 40TH ST STE 403
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33175-3595
Mailing Address - Country:US
Mailing Address - Phone:305-226-2020
Mailing Address - Fax:305-226-2018
Practice Address - Street 1:11760 SW 40TH ST STE 403
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33175-3595
Practice Address - Country:US
Practice Address - Phone:305-226-2020
Practice Address - Fax:305-226-2018
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-13
Last Update Date:2020-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME122730208800000X
GA74307208800000X
NY60 255424208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology