Provider Demographics
NPI:1285429571
Name:SPACE COAST MEDICAL CONSULTANTS PLLC
Entity type:Organization
Organization Name:SPACE COAST MEDICAL CONSULTANTS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:GAURAV
Authorized Official - Middle Name:
Authorized Official - Last Name:MATHUR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:321-621-0478
Mailing Address - Street 1:502 GARDEN ST
Mailing Address - Street 2:
Mailing Address - City:TITUSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32796-3405
Mailing Address - Country:US
Mailing Address - Phone:321-621-0478
Mailing Address - Fax:
Practice Address - Street 1:502 GARDEN ST
Practice Address - Street 2:
Practice Address - City:TITUSVILLE
Practice Address - State:FL
Practice Address - Zip Code:32796-3405
Practice Address - Country:US
Practice Address - Phone:321-621-0478
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-04-09
Last Update Date:2025-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RA0401XAllopathic & Osteopathic PhysiciansInternal MedicineAddiction MedicineGroup - Multi-Specialty