Provider Demographics
NPI:1629003579
Name:PERUMAL, AMUDHA MANI (MD)
Entity Type:Individual
Prefix:
First Name:AMUDHA
Middle Name:MANI
Last Name:PERUMAL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:140 HISTORIC BRICK LN
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32095-8020
Mailing Address - Country:US
Mailing Address - Phone:904-829-9919
Mailing Address - Fax:904-829-2617
Practice Address - Street 1:1201 ARAPAHO AVE
Practice Address - Street 2:
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32084-4258
Practice Address - Country:US
Practice Address - Phone:904-829-9919
Practice Address - Fax:904-829-2617
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2016-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME766932084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
K2035Medicare UPIN