Healthcare Provider Details

I. General information

NPI: 1316202682
Provider Name (Legal Business Name): GRACE SARVOTHAM MD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/11/2012
Last Update Date: 07/11/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

630 MAIN ST
ALTAMONTE SPRINGS FL
32701-6413
US

IV. Provider business mailing address

630 MAIN ST
ALTAMONTE SPRINGS FL
32701-6413
US

V. Phone/Fax

Practice location:
  • Phone: 407-339-6148
  • Fax: 407-339-0254
Mailing address:
  • Phone: 407-339-6148
  • Fax: 407-339-0254

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VX0000X
TaxonomyObstetrics Physician
License NumberME42498
License Number StateFL

VIII. Authorized Official

Name: SAMEENA PARVEZ
Title or Position: ADMINISTRATOR
Credential:
Phone: 407-339-6148