Healthcare Provider Details

I. General information

NPI: 1811286693
Provider Name (Legal Business Name): SANGY PAUL POTTACKAL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/01/2011
Last Update Date: 05/12/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12901 BRUCE B DOWNS BLVD MDC 41
TAMPA FL
33612-4742
US

IV. Provider business mailing address

2700 UNIVERSITY SQUARE DR
TAMPA FL
33612-5513
US

V. Phone/Fax

Practice location:
  • Phone: 813-974-3680
  • Fax:
Mailing address:
  • Phone: 813-253-2721
  • Fax: 813-977-3720

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberME127595
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: