Healthcare Provider Details

I. General information

NPI: 1649269689
Provider Name (Legal Business Name): KRISHNAKANTHAN SASANKAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/20/2005
Last Update Date: 12/28/2023
Certification Date: 12/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 SW ARCHER RD
GAINESVILLE FL
32610-5102
US

IV. Provider business mailing address

PO BOX 100296
GAINESVILLE FL
32610-3003
US

V. Phone/Fax

Practice location:
  • Phone: 352-265-0111
  • Fax:
Mailing address:
  • Phone: 352-627-9350
  • Fax: 352-273-9054

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number193354
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME161851
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: