Healthcare Provider Details

I. General information

NPI: 1376793331
Provider Name (Legal Business Name): SUDARSAN R KAMISETTY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/26/2008
Last Update Date: 09/26/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

681 W LUMSDEN RD
BRANDON FL
33511-5911
US

IV. Provider business mailing address

681 W LUMSDEN RD
BRANDON FL
33511-5911
US

V. Phone/Fax

Practice location:
  • Phone: 813-655-7726
  • Fax: 813-655-5617
Mailing address:
  • Phone: 813-655-7726
  • Fax: 813-655-5617

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License NumberME70832
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: