Healthcare Provider Details

I. General information

NPI: 1962587139
Provider Name (Legal Business Name): SUNITA TIKKU M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SUNITA KOTHA M.B., B.S.

II. Dates (important events)

Enumeration Date: 10/26/2006
Last Update Date: 10/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1061 MEDICAL CENTER DR STE 205
ORANGE CITY FL
32763-8226
US

IV. Provider business mailing address

1061 MEDICAL CENTER DR STE 205
ORANGE CITY FL
32763-8226
US

V. Phone/Fax

Practice location:
  • Phone: 386-917-7610
  • Fax: 386-917-7615
Mailing address:
  • Phone: 386-917-7610
  • Fax: 386-917-7615

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number25MA07725800
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberME100501
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: