=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679568133
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | VIDYASAGAR REDDY VANGALA M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/12/2005
-----------------------------------------------------
Last Update Date | 06/07/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2504 SAND MINE RD
-----------------------------------------------------
City | DAVENPORT
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33897-3402
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 863-419-7645
-----------------------------------------------------
Fax | 863-419-7655
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1 SOUTH BLVD E # 1020
-----------------------------------------------------
City | DAVENPORT
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33837-7547
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 863-419-7645
-----------------------------------------------------
Fax | 863-419-7655
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number | ME82811
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------