Healthcare Provider Details

I. General information

NPI: 1366403867
Provider Name (Legal Business Name): SUNDEEP MEDIRATTA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/01/2006
Last Update Date: 11/28/2023
Certification Date: 11/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

805 OAKLEY SEAVER DR STE A
CLERMONT FL
34711-1968
US

IV. Provider business mailing address

1723 LUCERNE TER STE 100
ORLANDO FL
32806-2916
US

V. Phone/Fax

Practice location:
  • Phone: 407-738-4200
  • Fax: 407-705-2540
Mailing address:
  • Phone: 407-738-4200
  • Fax: 407-650-1307

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberME85297
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code207RA0001X
TaxonomyAdvanced Heart Failure and Transplant Cardiology Physician
License NumberME85297
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: