Healthcare Provider Details

I. General information

NPI: 1467431064
Provider Name (Legal Business Name): OLGA GRAJALES MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/11/2006
Last Update Date: 10/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1389 S US 301
SUMTERVILLE FL
33585-5143
US

IV. Provider business mailing address

1425 S US 301
SUMTERVILLE FL
33585-5141
US

V. Phone/Fax

Practice location:
  • Phone: 352-793-5900
  • Fax:
Mailing address:
  • Phone: 352-793-5900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number5556
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: