Healthcare Provider Details

I. General information

NPI: 1255331666
Provider Name (Legal Business Name): VASCULAR CENTER OF ORLANDO, P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/28/2005
Last Update Date: 10/10/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 EDGEWATER DR
ORLANDO FL
32804-6314
US

IV. Provider business mailing address

1200 EDGEWATER DR
ORLANDO FL
32804-6314
US

V. Phone/Fax

Practice location:
  • Phone: 407-244-8559
  • Fax: 407-244-8560
Mailing address:
  • Phone: 407-244-8559
  • Fax: 407-244-8560

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License NumberME31846
License Number StateFL

VIII. Authorized Official

Name: SAMUEL PRESTON MARTIN IV
Title or Position: OWNER
Credential: M.D.
Phone: 407-244-8559