MEDICARE: DR. VATTI THECKLA ANTHONY MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	ME135162	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	VVN40	OTHER	FL	FLORIDA BLUE
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1205884590
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. VATTI THECKLA ANTHONY MD

Provider Business Mailing Address
First Line	:	PO BOX 417
Second Line	:
City	:	STUART
State	:	FL
Zip	:	34995-0417
Country	:	US
Telephone Number	:	772-223-2832
Fax Number	:	772-223-5652

Provider Business Practice Location Address
First Line	:	2392 SE OCEAN BLVD
Second Line	:
City	:	STUART
State	:	FL
Zip	:	34996-3310
Country	:	US
Telephone Number	:	772-223-5628
Fax Number	:	772-223-5652

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/05/2006
Last Update Date	:	09/07/2018

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