Provider Demographics
NPI:1043279524
Name:VANGORE, SURYA K (MD PC)
Entity Type:Individual
Prefix:DR
First Name:SURYA
Middle Name:K
Last Name:VANGORE
Suffix:
Gender:F
Credentials:MD PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:431 W ROOSEVELT BLVD
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19120-4148
Mailing Address - Country:US
Mailing Address - Phone:215-455-3444
Mailing Address - Fax:215-455-3445
Practice Address - Street 1:431 W ROOSEVELT BLVD
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19120-4148
Practice Address - Country:US
Practice Address - Phone:215-455-3444
Practice Address - Fax:215-455-3445
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-22
Last Update Date:2020-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD038910L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0094066901Medicaid
PA0094066901Medicaid
PAC34290Medicare UPIN