Provider Demographics
NPI:1558460667
Name:EYYUNNI, RAMANUJAM S (MD)
Entity Type:Individual
Prefix:
First Name:RAMANUJAM
Middle Name:S
Last Name:EYYUNNI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:RAMANUJAM
Other - Middle Name:
Other - Last Name:EYYUNNI
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 3123
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32085-3123
Mailing Address - Country:US
Mailing Address - Phone:904-824-4990
Mailing Address - Fax:904-824-2226
Practice Address - Street 1:201 HEALTH PARK BLVD
Practice Address - Street 2:SUITE 107
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32086-5796
Practice Address - Country:US
Practice Address - Phone:904-819-0101
Practice Address - Fax:904-825-4759
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-22
Last Update Date:2017-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME81943208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLP00433993OtherRR MEDICARE
FL262442700Medicaid
FL51164ZMedicare PIN
FLP00433993OtherRR MEDICARE