Healthcare Provider Details

I. General information

NPI: 1053694539
Provider Name (Legal Business Name): TASSCIA M WILLIAMS SOUFFRANT MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/21/2011
Last Update Date: 03/07/2023
Certification Date: 10/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

61 THOMAS JOHNSON DR
FREDERICK MD
21702-4301
US

IV. Provider business mailing address

3300 S FISKE BLVD
ROCKLEDGE FL
32955-4306
US

V. Phone/Fax

Practice location:
  • Phone: 301-663-6171
  • Fax: 301-695-4469
Mailing address:
  • Phone: 321-361-5615
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberMD458253
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberD85692
License Number StateMD
# 3
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberME149269
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: