Provider Demographics
NPI:1316202682
Name:GRACE SARVOTHAM MD
Entity Type:Organization
Organization Name:GRACE SARVOTHAM MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:SAMEENA
Authorized Official - Middle Name:
Authorized Official - Last Name:PARVEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-339-6148
Mailing Address - Street 1:630 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ALTAMONTE SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32701-6413
Mailing Address - Country:US
Mailing Address - Phone:407-339-6148
Mailing Address - Fax:407-339-0254
Practice Address - Street 1:630 MAIN ST
Practice Address - Street 2:
Practice Address - City:ALTAMONTE SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:32701-6413
Practice Address - Country:US
Practice Address - Phone:407-339-6148
Practice Address - Fax:407-339-0254
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-11
Last Update Date:2012-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME42498207VX0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL068265900Medicaid