Provider Demographics
NPI:1376983536
Name:MUKTHAPURAM, SHANMUKHA SAI (MD)
Entity Type:Individual
Prefix:
First Name:SHANMUKHA SAI
Middle Name:
Last Name:MUKTHAPURAM
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 1:3180 S OCEAN DR APT 1408
Mailing Address - Street 2:
Mailing Address - City:HALLANDALE BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33009-7252
Mailing Address - Country:US
Mailing Address - Phone:929-234-9843
Mailing Address - Fax:
Practice Address - Street 1:10101 FOREST HILL BLVD
Practice Address - Street 2:
Practice Address - City:WELLINGTON
Practice Address - State:FL
Practice Address - Zip Code:33414-6103
Practice Address - Country:US
Practice Address - Phone:561-798-8500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-02
Last Update Date:2024-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.128161208000000X
FLME1602152080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics