Healthcare Provider Details

I. General information

NPI: 1609165794
Provider Name (Legal Business Name): SUMEET THAREJA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/29/2011
Last Update Date: 02/15/2023
Certification Date: 02/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

675 S BABCOCK STREET
MELBOURNE FL
32901-1459
US

IV. Provider business mailing address

675 S BABCOCK STREET
MELBOURNE FL
32901-1459
US

V. Phone/Fax

Practice location:
  • Phone: 321-951-1010
  • Fax: 321-952-4038
Mailing address:
  • Phone: 321-951-1010
  • Fax: 321-952-4038

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberME123157
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: