MEDICARE: DR. VIDYASAGAR REDDY VANGALA M.D.

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	2084P0800X	Psychiatry Physician	ME82811	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	79180	OTHER		PTAN

General Provider Information

NPI Number	:	1679568133
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. VIDYASAGAR REDDY VANGALA M.D.

Provider Business Mailing Address
First Line	:	1 SOUTH BLVD E # 1020
Second Line	:
City	:	DAVENPORT
State	:	FL
Zip	:	33837-7547
Country	:	US
Telephone Number	:	863-419-7645
Fax Number	:	863-419-7655

Provider Business Practice Location Address
First Line	:	2504 SAND MINE RD
Second Line	:
City	:	DAVENPORT
State	:	FL
Zip	:	33897-3402
Country	:	US
Telephone Number	:	863-419-7645
Fax Number	:	863-419-7655

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

Provider Enumeration Date	:	09/12/2005
Last Update Date	:	06/07/2024

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