Healthcare Provider Details

I. General information

NPI: 1699691097
Provider Name (Legal Business Name): OVIEDO NEUROLOGY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/29/2026
Last Update Date: 06/29/2026
Certification Date: 06/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1410 W BROADWAY ST STE 104
OVIEDO FL
32765-6537
US

IV. Provider business mailing address

1410 W BROADWAY ST STE 104
OVIEDO FL
32765-6537
US

V. Phone/Fax

Practice location:
  • Phone: 407-447-7181
  • Fax: 407-447-7184
Mailing address:
  • Phone: 407-447-7181
  • Fax: 407-447-7184

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. SHASANKA THUMU
Title or Position: OWNER
Credential: OWNER
Phone: 407-447-7181