Provider Demographics
NPI:1336132844
Name:VISVALINGAM, BHANU (MD)
Entity Type:Individual
Prefix:DR
First Name:BHANU
Middle Name:
Last Name:VISVALINGAM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8461 RIVER BRANCH PL
Mailing Address - Street 2:
Mailing Address - City:SANFORD
Mailing Address - State:FL
Mailing Address - Zip Code:32771-8358
Mailing Address - Country:US
Mailing Address - Phone:386-216-0269
Mailing Address - Fax:
Practice Address - Street 1:5111 S RIDGEWOOD AVE STE 301
Practice Address - Street 2:
Practice Address - City:PORT ORANGE
Practice Address - State:FL
Practice Address - Zip Code:32127-5170
Practice Address - Country:US
Practice Address - Phone:386-304-7070
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-30
Last Update Date:2024-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME96546207RH0003X
FLME 96546207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL2767441-00Medicaid
FL2767441-00Medicaid
FLAA346ZMedicare PIN