Provider Demographics
NPI:1265934087
Name:GRACEMDCONNECT
Entity type:Organization
Organization Name:GRACEMDCONNECT
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DEEPA
Authorized Official - Middle Name:
Authorized Official - Last Name:SUKUMAR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-344-7062
Mailing Address - Street 1:11934 ANGLE POND AVE
Mailing Address - Street 2:
Mailing Address - City:WINDERMERE
Mailing Address - State:FL
Mailing Address - Zip Code:34786-6526
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11934 ANGLE POND AVE
Practice Address - Street 2:
Practice Address - City:WINDERMERE
Practice Address - State:FL
Practice Address - Zip Code:34786-6526
Practice Address - Country:US
Practice Address - Phone:718-344-7062
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GRACE MED PA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-03-07
Last Update Date:2018-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME122569208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty