Basic Information
| Provider Information | |||||||||
| NPI: | 1497781785 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | AGRAMA | ||||||||
| FirstName: | MARK | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 15280 NW 79TH CT STE 200 | ||||||||
| Address2: | |||||||||
| City: | MIAMI LAKES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 330165873 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3055583724 | ||||||||
| FaxNumber: | 7869074485 | ||||||||
| Practice Location | |||||||||
| Address1: | 550 HERITAGE DR STE 201 | ||||||||
| Address2: | |||||||||
| City: | JUPITER | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334583029 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5616245311 | ||||||||
| FaxNumber: | 5616254624 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/25/2006 | ||||||||
| LastUpdateDate: | 09/20/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/20/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207YS0012X | ME87650 | FL | N | Allopathic & Osteopathic Physicians | Otolaryngology | Sleep Medicine | 207Y00000X | ME87650 | FL | Y | Allopathic & Osteopathic Physicians | Otolaryngology |
ID Information
| ID | Type | State | Issuer | Description | 000737000 | 05 | FL | MEDICAID | 1169358 | 05 | LA | MEDICAID | 07033291 | 05 | MS | MEDICAID |