Basic Information
| Provider Information | |||||||||
| NPI: | 1366403867 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MEDIRATTA | ||||||||
| FirstName: | SUNDEEP | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2080 OAKLEY SEAVER DR | ||||||||
| Address2: | |||||||||
| City: | CLERMONT | ||||||||
| State: | FL | ||||||||
| PostalCode: | 347111962 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3218416444 | ||||||||
| FaxNumber: | 4076501307 | ||||||||
| Practice Location | |||||||||
| Address1: | 2080 OAKLEY SEAVER DR | ||||||||
| Address2: | |||||||||
| City: | CLERMONT | ||||||||
| State: | FL | ||||||||
| PostalCode: | 347111962 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3218416444 | ||||||||
| FaxNumber: | 4076501307 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/01/2006 | ||||||||
| LastUpdateDate: | 02/22/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | ME85297 | FL | N | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207RA0001X | ME85297 | FL | Y |
ID Information
| ID | Type | State | Issuer | Description | ME85297 | 01 | FL | MEDICAL LICENSE | OTHER | 265507100 | 05 | FL | MEDICAID |