Provider Demographics
NPI:1255331666
Name:VASCULAR CENTER OF ORLANDO, P.A.
Entity Type:Organization
Organization Name:VASCULAR CENTER OF ORLANDO, P.A.
Other - Org Name:VASCULAR CENTERS OF ORLANDO
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:PRESTON
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:IV
Authorized Official - Credentials:MD
Authorized Official - Phone:407-244-8559
Mailing Address - Street 1:1200 EDGEWATER DR
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32804-6314
Mailing Address - Country:US
Mailing Address - Phone:407-244-8559
Mailing Address - Fax:407-244-8560
Practice Address - Street 1:1200 EDGEWATER DR
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32804-6314
Practice Address - Country:US
Practice Address - Phone:407-244-8559
Practice Address - Fax:407-244-8560
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-28
Last Update Date:2012-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME318462086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL037049500Medicaid
FL060065287OtherCHAMPUS
FLK3247Medicare ID - Type UnspecifiedGROUP