MEDICARE: DIABETES VIRTUAL CLINIC LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207RE0101X	Endocrinology, Diabetes & Metabolism Physician

General Provider Information

NPI Number	:	1952184368
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DIABETES VIRTUAL CLINIC LLC

Provider Business Mailing Address
First Line	:	4903 W BAY WAY DR
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33629-4803
Country	:	US
Telephone Number	:	727-345-5222
Fax Number	:	727-345-4066

Provider Business Practice Location Address
First Line	:	4903 W BAY WAY DR
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33629-4803
Country	:	US
Telephone Number	:	727-345-5222
Fax Number	:	727-345-4066

Authorized Official
Title or Position	:	PRESIDENT
Name	:	AJAY VARANASI
Credential	:	M.D.
Telephone Number	:	727-269-5618

Provider Enumeration Date	:	08/17/2023
Last Update Date	:	08/17/2023

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