Provider Demographics
NPI:1336676501
Name:MADHUN, MECCA GRACE (DO)
Entity Type:Individual
Prefix:DR
First Name:MECCA
Middle Name:GRACE
Last Name:MADHUN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 WATERMAN WAY
Mailing Address - Street 2:
Mailing Address - City:TAVARES
Mailing Address - State:FL
Mailing Address - Zip Code:32778-5266
Mailing Address - Country:US
Mailing Address - Phone:352-253-3333
Mailing Address - Fax:
Practice Address - Street 1:3000 ARLINGTON AVE # MS 1088
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43614-2595
Practice Address - Country:US
Practice Address - Phone:419-383-6369
Practice Address - Fax:419-383-3357
Is Sole Proprietor?:No
Enumeration Date:2017-05-18
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
OH34.014127207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program