Provider Demographics
NPI:1609165794
Name:THAREJA, SUMEET (MD)
Entity Type:Individual
Prefix:MR
First Name:SUMEET
Middle Name:
Last Name:THAREJA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:675 S BABCOCK STREET
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32901-1459
Mailing Address - Country:US
Mailing Address - Phone:321-951-1010
Mailing Address - Fax:321-952-4038
Practice Address - Street 1:675 S BABCOCK STREET
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-1459
Practice Address - Country:US
Practice Address - Phone:321-951-1010
Practice Address - Fax:321-952-4038
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-29
Last Update Date:2023-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
FLME123157174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLID365ZMedicare PIN