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General NPI Number Information
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NPI Number | 1699109181
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Entity Type | Organization
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Legal Business Name | SOUTHERN VASCULAR OF PANAMA CITY PLLC
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Dates
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Enumeration Date | 09/03/2013
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Last Update Date | 09/16/2019
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Provider Practice Location Address
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Address Line | 1399 JENKS AVE # 12
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City | PANAMA CITY
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State | FL
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Zip | 32401-2442
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Country | US
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Telephone | 850-532-6303
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Fax | 850-307-5402
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Provider Business Mailing Address
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Address Line | 1399 JENKS AVE # 12
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City | PANAMA CITY
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State | FL
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Zip | 32401-2442
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Country | US
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Telephone | 850-532-6303
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Fax | 850-307-5402
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Authorized Official
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Title or Position | PHYSICIAN/OWNER
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Name | ASHISH K GUPTA
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Credential | MD
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Telephone | 850-896-1696
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2086S0129X
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Taxonomy Name | Vascular Surgery Physician
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License Number |
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License Number State | FL
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