Provider Demographics
NPI:1962587139
Name:TIKKU, SUNITA (MD)
Entity type:Individual
Prefix:
First Name:SUNITA
Middle Name:
Last Name:TIKKU
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:SUNITA
Other - Middle Name:
Other - Last Name:KOTHA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MB, BS
Mailing Address - Street 1:1061 MEDICAL CENTER DR STE 205
Mailing Address - Street 2:
Mailing Address - City:ORANGE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32763-8226
Mailing Address - Country:US
Mailing Address - Phone:386-917-7610
Mailing Address - Fax:386-917-7615
Practice Address - Street 1:1061 MEDICAL CENTER DR STE 205
Practice Address - Street 2:
Practice Address - City:ORANGE CITY
Practice Address - State:FL
Practice Address - Zip Code:32763-8226
Practice Address - Country:US
Practice Address - Phone:386-917-7610
Practice Address - Fax:386-917-7615
Is Sole Proprietor?:No
Enumeration Date:2006-10-26
Last Update Date:2019-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA077258002084P0800X
FLME1005012084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ4144007Medicaid
I16314Medicare UPIN
NJ083232Medicare PIN
NJ4144007Medicaid