Provider Demographics
NPI:1679576805
Name:MUSUNURU, SAMBASIVA K RAO (MD)
Entity Type:Individual
Prefix:DR
First Name:SAMBASIVA
Middle Name:K RAO
Last Name:MUSUNURU
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 1:14100 FIVAY RD
Mailing Address - Street 2:STE 160
Mailing Address - City:HUDSON
Mailing Address - State:FL
Mailing Address - Zip Code:34667-7194
Mailing Address - Country:US
Mailing Address - Phone:727-862-1080
Mailing Address - Fax:727-863-3093
Practice Address - Street 1:14100 FIVAY RD
Practice Address - Street 2:
Practice Address - City:HUDSON
Practice Address - State:FL
Practice Address - Zip Code:34667-7180
Practice Address - Country:US
Practice Address - Phone:727-862-1080
Practice Address - Fax:727-863-3093
Is Sole Proprietor?:No
Enumeration Date:2005-05-23
Last Update Date:2017-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 37395207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL252929700Medicaid
FL51138Medicare PIN
FL252929700Medicaid