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General NPI Number Information
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NPI Number | 1285429571
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Entity Type | Organization
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Legal Business Name | SPACE COAST MEDICAL CONSULTANTS PLLC
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Dates
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Enumeration Date | 04/09/2025
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Last Update Date | 04/09/2025
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Provider Practice Location Address
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Address Line | 502 GARDEN ST
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City | TITUSVILLE
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State | FL
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Zip | 32796-3405
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Country | US
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Telephone | 321-621-0478
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Fax |
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Provider Business Mailing Address
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Address Line | 502 GARDEN ST
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City | TITUSVILLE
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State | FL
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Zip | 32796-3405
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Country | US
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Telephone | 321-621-0478
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | GAURAV MATHUR
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Credential | MD
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Telephone | 321-621-0478
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207RA0401X
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Taxonomy Name | Addiction Medicine (Internal Medicine) Physician
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number |
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License Number State |
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