Provider Demographics
NPI:1720237290
Name:GUJARATHI, MAYURA PRAKASH (MD)
Entity Type:Individual
Prefix:
First Name:MAYURA
Middle Name:PRAKASH
Last Name:GUJARATHI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3530 SW 22ND ST
Mailing Address - Street 2:APT 706
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33145-3254
Mailing Address - Country:US
Mailing Address - Phone:313-405-3302
Mailing Address - Fax:
Practice Address - Street 1:3100 SW 62ND AVE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33155
Practice Address - Country:US
Practice Address - Phone:786-624-3588
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-09
Last Update Date:2012-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301091793208000000X
FLME 1097892080P0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0204XAllopathic & Osteopathic PhysiciansPediatricsPediatric Emergency Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics