Provider Demographics
NPI:1639397904
Name:GRACEN, TODD LEE (MD)
Entity Type:Individual
Prefix:
First Name:TODD
Middle Name:LEE
Last Name:GRACEN
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 1:1209 LAKESIDE DR
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33510-4109
Mailing Address - Country:US
Mailing Address - Phone:813-661-3662
Mailing Address - Fax:
Practice Address - Street 1:1209 LAKESIDE DR
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33510-4109
Practice Address - Country:US
Practice Address - Phone:813-661-3662
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-23
Last Update Date:2015-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 67237207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLC49005Medicare UPIN