Provider Demographics
NPI:1124210281
Name:VANCE, SUSHMA K (MD)
Entity Type:Individual
Prefix:MS
First Name:SUSHMA
Middle Name:K
Last Name:VANCE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MS
Other - First Name:SUSHMA
Other - Middle Name:
Other - Last Name:KANDULA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:6207 BENNETT RD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-5007
Mailing Address - Country:US
Mailing Address - Phone:941-241-7865
Mailing Address - Fax:407-470-1043
Practice Address - Street 1:6207 BENNETT RD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-5007
Practice Address - Country:US
Practice Address - Phone:904-241-7865
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-13
Last Update Date:2024-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME122617207W00000X, 207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL014425300Medicaid
FLME122617OtherLISCENCE
FLIB802ZMedicare PIN
TXTXB103585Medicare PIN
TXTXB103587Medicare PIN
TXTXB103588Medicare PIN
TX212671603Medicaid
TX212671606Medicaid
FLIB802ZMedicare PIN
TXP00889639Medicare PIN
TXTXB103586Medicare PIN
FLME122617OtherLISCENCE
FL014425300Medicaid
TX212671601Medicaid
TX212671602Medicaid
TXTXB103589Medicare PIN