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General NPI Number Information
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NPI Number | 1265934087
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Entity Type | Organization
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Legal Business Name | GRACEMDCONNECT
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Dates
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Enumeration Date | 03/07/2018
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Last Update Date | 03/07/2018
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Provider Practice Location Address
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Address Line | 11934 ANGLE POND AVE
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City | WINDERMERE
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State | FL
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Zip | 34786-6526
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Country | US
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Telephone | 718-344-7062
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Fax |
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Provider Business Mailing Address
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Address Line | 11934 ANGLE POND AVE
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City | WINDERMERE
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State | FL
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Zip | 34786-6526
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. DEEPA SUKUMAR
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Credential | MD
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Telephone | 718-344-7062
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number | ME122569
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License Number State | FL
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