Provider Demographics
NPI:1124220132
Name:VANGURA, KARIN HERZELE (MD)
Entity Type:Individual
Prefix:DR
First Name:KARIN
Middle Name:HERZELE
Last Name:VANGURA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:705 WELLS RD STE 300
Mailing Address - Street 2:
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32073-2982
Mailing Address - Country:US
Mailing Address - Phone:904-282-6331
Mailing Address - Fax:904-619-1080
Practice Address - Street 1:1564 KINGSLEY AVE
Practice Address - Street 2:
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32073-4521
Practice Address - Country:US
Practice Address - Phone:904-282-6331
Practice Address - Fax:904-619-1080
Is Sole Proprietor?:No
Enumeration Date:2007-06-01
Last Update Date:2022-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301088270207L00000X
FLME108223207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL004623200Medicaid