Healthcare Provider Details

I. General information

NPI: 1609892553
Provider Name (Legal Business Name): GRACIELA O DEBOCCARDO MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2006
Last Update Date: 01/24/2025
Certification Date: 01/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2852 TAMIAMI TRL STE 1
PORT CHARLOTTE FL
33952-5100
US

IV. Provider business mailing address

2852 TAMIAMI TRL STE 1
PORT CHARLOTTE FL
33952-5100
US

V. Phone/Fax

Practice location:
  • Phone: 941-505-8720
  • Fax: 941-505-8747
Mailing address:
  • Phone: 941-505-8720
  • Fax: 941-505-8747

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number134410
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: