Provider Demographics
NPI:1437289188
Name:LEGRANDE, SYDEL (MD)
Entity Type:Individual
Prefix:
First Name:SYDEL
Middle Name:
Last Name:LEGRANDE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4816 N ARMENIA AVE
Mailing Address - Street 2:STE. A
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33603-1400
Mailing Address - Country:US
Mailing Address - Phone:813-443-0866
Mailing Address - Fax:813-225-1583
Practice Address - Street 1:4816 N ARMENIA AVE
Practice Address - Street 2:STE. A
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33603-1400
Practice Address - Country:US
Practice Address - Phone:813-443-0866
Practice Address - Fax:813-225-1583
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-06
Last Update Date:2015-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0047234207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL042392100Medicaid
FL042392100Medicaid
FL04827AMedicare ID - Type Unspecified