Provider Demographics
NPI:1811993355
Name:VAZRALA, SUSHAMA (MD)
Entity type:Individual
Prefix:DR
First Name:SUSHAMA
Middle Name:
Last Name:VAZRALA
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 1:10000 BAY PINES BLVD, BUILDING 101
Mailing Address - Street 2:
Mailing Address - City:BAY PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33744-8200
Mailing Address - Country:US
Mailing Address - Phone:727-398-6661
Mailing Address - Fax:
Practice Address - Street 1:1609 PASADENA AVE S
Practice Address - Street 2:SUITE 3A
Practice Address - City:SOUTH PASADENA
Practice Address - State:FL
Practice Address - Zip Code:33707-4565
Practice Address - Country:US
Practice Address - Phone:727-345-5700
Practice Address - Fax:727-345-5755
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-21
Last Update Date:2016-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME88785207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL268492600Medicaid
FLI00524Medicare UPIN
FL268492600Medicaid