Healthcare Provider Details

I. General information

NPI: 1770548679
Provider Name (Legal Business Name): VASUNDHARA G IYENGAR M. D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/20/2006
Last Update Date: 11/13/2021
Certification Date: 11/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1920 DON WICKHAM DR STE 100
CLERMONT FL
34711-1977
US

IV. Provider business mailing address

4371 VERONICA S SHOEMAKER BLVD ATTN: CREDENTIAL DEPARTMENT
FORT MYERS FL
33916-2216
US

V. Phone/Fax

Practice location:
  • Phone: 352-394-1150
  • Fax: 352-394-1560
Mailing address:
  • Phone: 239-274-8200
  • Fax: 239-278-3350

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RH0000X
TaxonomyHematology (Internal Medicine) Physician
License NumberME0044726
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code207RX0202X
TaxonomyMedical Oncology Physician
License NumberME0044726
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: