Healthcare Provider Details

I. General information

NPI: 1023335437
Provider Name (Legal Business Name): WEST VOLUSIA SURGICAL, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/23/2010
Last Update Date: 11/24/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

321 MONTGOMERY RD #160965
ALTAMONTE SPRINGS FL
32716-0965
US

IV. Provider business mailing address

321 MONTGOMERY RD #160965
ALTAMONTE SPRINGS FL
32716-0965
US

V. Phone/Fax

Practice location:
  • Phone: 407-409-8111
  • Fax: 407-409-8115
Mailing address:
  • Phone: 407-409-8111
  • Fax: 407-409-8115

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberME98314
License Number StateFL

VIII. Authorized Official

Name: SAMUEL R OGLE
Title or Position: PRESIDENT
Credential: M.D.
Phone: 407-443-1865