Provider Demographics
NPI:1306827027
Name:CHUDASAMA, PRADYUMAN M (MD)
Entity Type:Individual
Prefix:DR
First Name:PRADYUMAN
Middle Name:M
Last Name:CHUDASAMA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6101 BLUE LAGOON DR STE 400
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33126-2051
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3641 CLYDE MORRIS BLVD STE 100
Practice Address - Street 2:
Practice Address - City:PORT ORANGE
Practice Address - State:FL
Practice Address - Zip Code:32129-2357
Practice Address - Country:US
Practice Address - Phone:386-675-4410
Practice Address - Fax:866-542-5859
Is Sole Proprietor?:No
Enumeration Date:2005-11-09
Last Update Date:2021-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME66912207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
F91326Medicare UPIN
25755XMedicare ID - Type Unspecified