Healthcare Provider Details

I. General information

NPI: 1750489043
Provider Name (Legal Business Name): VIRABANDITH VICTOR SONGBANDITH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 08/04/2025
Certification Date: 08/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16521 S US HIGHWAY 301
WIMAUMA FL
33598-2032
US

IV. Provider business mailing address

PO BOX 1289
TAMPA FL
33601-1289
US

V. Phone/Fax

Practice location:
  • Phone: 813-844-4700
  • Fax:
Mailing address:
  • Phone: 813-844-8927
  • Fax: 915-603-4282

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberL0612
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberME166832
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: