Healthcare Provider Details

I. General information

NPI: 1669737706
Provider Name (Legal Business Name): VAMSI NUKALA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/04/2012
Last Update Date: 02/23/2023
Certification Date: 02/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1501 S PINELLAS AVE STE G
TARPON SPRINGS FL
34689-1950
US

IV. Provider business mailing address

1501 S PINELLAS AVE STE G
TARPON SPRINGS FL
34689-1950
US

V. Phone/Fax

Practice location:
  • Phone: 727-943-3405
  • Fax:
Mailing address:
  • Phone: 727-943-3405
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number35125917
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number036.142028
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberME156034
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: