Healthcare Provider Details

I. General information

NPI: 1093335937
Provider Name (Legal Business Name): VIKRAM ETTIGOUNDER PONNUSAMY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/21/2020
Last Update Date: 07/09/2026
Certification Date: 07/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

95 COLUMBIA ST
ORLANDO FL
32806-1101
US

IV. Provider business mailing address

95 COLUMBIA ST
ORLANDO FL
32806-1101
US

V. Phone/Fax

Practice location:
  • Phone: 407-849-9621
  • Fax: 407-420-4056
Mailing address:
  • Phone: 407-849-9621
  • Fax: 904-996-1446

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207WX0107X
TaxonomyRetina Specialist (Ophthalmology) Physician
License NumberME177994
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberME177994
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: