Healthcare Provider Details

I. General information

NPI: 1881942779
Provider Name (Legal Business Name): LEGACY HEALTH MEDICAL GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/27/2012
Last Update Date: 09/26/2025
Certification Date: 09/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 W BAY DR STE 605
LARGO FL
33770-3268
US

IV. Provider business mailing address

801 W BAY DR STE 605
LARGO FL
33770-3268
US

V. Phone/Fax

Practice location:
  • Phone: 727-489-3305
  • Fax: 727-499-9559
Mailing address:
  • Phone: 727-489-3305
  • Fax: 727-499-9559

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number
License Number StateNULL
# 5
Primary TaxonomyN
Taxonomy Code163WW0000X
TaxonomyWound Care Registered Nurse
License Number
License Number StateNULL
# 6
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateNULL
# 7
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number StateNULL
# 8
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberME105069
License Number StateFL

VIII. Authorized Official

Name: DR. SUNIT SRIVASTAVA
Title or Position: MANAGING MEMBER
Credential: M.D.
Phone: 727-644-1540