Provider Demographics
NPI:1336131481
Name:SASTRY, VATSALA S (MD)
Entity Type:Individual
Prefix:
First Name:VATSALA
Middle Name:S
Last Name:SASTRY
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 1:15435 CORTEZ BLVD
Mailing Address - Street 2:
Mailing Address - City:BROOKSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:34613-6113
Mailing Address - Country:US
Mailing Address - Phone:352-799-2294
Mailing Address - Fax:352-796-8196
Practice Address - Street 1:15435 CORTEZ BLVD
Practice Address - Street 2:
Practice Address - City:BROOKSVILLE
Practice Address - State:FL
Practice Address - Zip Code:34613-6113
Practice Address - Country:US
Practice Address - Phone:352-799-2294
Practice Address - Fax:352-796-8196
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-16
Last Update Date:2011-12-19
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLME68115207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL377455402Medicaid
FLG00799Medicare UPIN
FL26860YMedicare ID - Type Unspecified