1700803657 NPI number — DR. GRACE V SARVOTHAM M.D.

Table of content: DR. GRACE V SARVOTHAM M.D. (NPI 1700803657)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700803657 NPI number — DR. GRACE V SARVOTHAM M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SARVOTHAM
Provider First Name:
GRACE
Provider Middle Name:
V
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1700803657
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/07/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
918 CANTON ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ORLANDO
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32803-3207
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
407-339-6148
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
630 MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ALTAMONTE SPRINGS
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32701-6413
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
407-339-6148
Provider Business Practice Location Address Fax Number:
407-339-0254
Provider Enumeration Date:
07/16/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207V00000X , with the licence number:  ME42498 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 068265900 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 100737700 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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