Healthcare Provider Details

I. General information

NPI: 1407048028
Provider Name (Legal Business Name): KOUSALYA SARA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KOUSALYA PENDELA M.D

II. Dates (important events)

Enumeration Date: 08/16/2007
Last Update Date: 06/03/2020
Certification Date: 06/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2700 HEALING WAY STE 303
WESLEY CHAPEL FL
33543-5471
US

IV. Provider business mailing address

2700 HEALING WAY STE 303
WESLEY CHAPEL FL
33543-5471
US

V. Phone/Fax

Practice location:
  • Phone: 813-929-5380
  • Fax: 813-929-5991
Mailing address:
  • Phone: 813-929-5380
  • Fax: 813-929-5991

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number60230
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME99943
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: