Provider Demographics
NPI:1407048028
Name:SARA, KOUSALYA (MD)
Entity Type:Individual
Prefix:
First Name:KOUSALYA
Middle Name:
Last Name:SARA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:KOUSALYA
Other - Middle Name:
Other - Last Name:PENDELA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:2700 HEALING WAY STE 303
Mailing Address - Street 2:
Mailing Address - City:WESLEY CHAPEL
Mailing Address - State:FL
Mailing Address - Zip Code:33543-5471
Mailing Address - Country:US
Mailing Address - Phone:813-929-5380
Mailing Address - Fax:813-929-5991
Practice Address - Street 1:2700 HEALING WAY STE 303
Practice Address - Street 2:
Practice Address - City:WESLEY CHAPEL
Practice Address - State:FL
Practice Address - Zip Code:33543-5471
Practice Address - Country:US
Practice Address - Phone:813-929-5380
Practice Address - Fax:813-929-5991
Is Sole Proprietor?:No
Enumeration Date:2007-08-16
Last Update Date:2020-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA60230208000000X
FLME99943208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLME99943OtherFLORIDA BOARD OF MEDICINE
GA60230OtherGA MEDICAL LICENSE