Provider Demographics
NPI:1679568133
Name:VANGALA, VIDYASAGAR REDDY (MD)
Entity type:Individual
Prefix:DR
First Name:VIDYASAGAR
Middle Name:REDDY
Last Name:VANGALA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1 SOUTH BLVD E # 1020
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:FL
Mailing Address - Zip Code:33837-7547
Mailing Address - Country:US
Mailing Address - Phone:863-419-7645
Mailing Address - Fax:863-419-7655
Practice Address - Street 1:2504 SAND MINE RD
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:FL
Practice Address - Zip Code:33897-3402
Practice Address - Country:US
Practice Address - Phone:863-419-7645
Practice Address - Fax:863-419-7655
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-12
Last Update Date:2024-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME828112084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL267311800Medicaid
79180OtherPTAN
FLG62736Medicare UPIN
FL79180Medicare PIN