Basic Information
| Provider Information | |||||||||
| NPI: | 1134450869 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RAO | ||||||||
| FirstName: | SURENDAR | ||||||||
| MiddleName: | GAJENDRA | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 14750 NW 77TH CT STE 100 | ||||||||
| Address2: | |||||||||
| City: | MIAMI LAKES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 330161507 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7867583152 | ||||||||
| FaxNumber: | 7864412156 | ||||||||
| Practice Location | |||||||||
| Address1: | 3345 BURNS RD STE 302 | ||||||||
| Address2: | |||||||||
| City: | PALM BEACH GARDENS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334104321 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5616227661 | ||||||||
| FaxNumber: | 5616224651 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/20/2010 | ||||||||
| LastUpdateDate: | 10/20/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/20/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | EP10034290 | TX | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 62640-20 | WI | N | Allopathic & Osteopathic Physicians | Family Medicine | 208D00000X | ACN702 | FL | N | Allopathic & Osteopathic Physicians | General Practice | 208D00000X | ME136965 | FL | Y | Allopathic & Osteopathic Physicians | General Practice |
No ID Information.