Provider Demographics
NPI:1194037044
Name:DASARI, MAYURI (MD)
Entity Type:Individual
Prefix:DR
First Name:MAYURI
Middle Name:
Last Name:DASARI
Suffix:
Gender:F
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:PO BOX 746723
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-6723
Mailing Address - Country:US
Mailing Address - Phone:127-339-7303
Mailing Address - Fax:773-866-8014
Practice Address - Street 1:462 N TELEGRAPH RD
Practice Address - Street 2:
Practice Address - City:PONTIAC
Practice Address - State:MI
Practice Address - Zip Code:48341-1037
Practice Address - Country:US
Practice Address - Phone:248-234-7540
Practice Address - Fax:248-581-8716
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-08
Last Update Date:2022-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125.058795207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine