Healthcare Provider Details

I. General information

NPI: 1265934087
Provider Name (Legal Business Name): GRACEMDCONNECT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/07/2018
Last Update Date: 03/07/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11934 ANGLE POND AVE
WINDERMERE FL
34786-6526
US

IV. Provider business mailing address

11934 ANGLE POND AVE
WINDERMERE FL
34786-6526
US

V. Phone/Fax

Practice location:
  • Phone: 718-344-7062
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME122569
License Number StateFL

VIII. Authorized Official

Name: DR. DEEPA SUKUMAR
Title or Position: PRESIDENT
Credential: MD
Phone: 718-344-7062