Healthcare Provider Details

I. General information

NPI: 1740082007
Provider Name (Legal Business Name): SUDEEP GC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/26/2025
Last Update Date: 03/26/2025
Certification Date: 03/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

940 BELMONT ST BLDG 2
BROCKTON MA
02301-5596
US

IV. Provider business mailing address

133 TAYLOR ST
MALDEN MA
02148-8021
US

V. Phone/Fax

Practice location:
  • Phone: 774-826-2079
  • Fax:
Mailing address:
  • Phone: 205-413-0878
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number2278501
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: