Healthcare Provider Details

I. General information

NPI: 1679568133
Provider Name (Legal Business Name): VIDYASAGAR REDDY VANGALA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/12/2005
Last Update Date: 06/07/2024
Certification Date: 06/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2504 SAND MINE RD
DAVENPORT FL
33897-3402
US

IV. Provider business mailing address

1 SOUTH BLVD E # 1020
DAVENPORT FL
33837-7547
US

V. Phone/Fax

Practice location:
  • Phone: 863-419-7645
  • Fax: 863-419-7655
Mailing address:
  • Phone: 863-419-7645
  • Fax: 863-419-7655

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberME82811
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: