Provider Demographics
NPI:1477619559
Name:TATAMBHOTLA, ANU (MD)
Entity Type:Individual
Prefix:
First Name:ANU
Middle Name:
Last Name:TATAMBHOTLA
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:PO BOX 5069
Mailing Address - Street 2:
Mailing Address - City:HOMOSASSA SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:34447-5069
Mailing Address - Country:US
Mailing Address - Phone:352-628-1000
Mailing Address - Fax:352-628-1120
Practice Address - Street 1:4049 S OHIO AVE
Practice Address - Street 2:
Practice Address - City:HOMOSASSA
Practice Address - State:FL
Practice Address - Zip Code:34446-1138
Practice Address - Country:US
Practice Address - Phone:352-628-1000
Practice Address - Fax:352-628-1120
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-31
Last Update Date:2009-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME73760207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL42870AMedicare PIN
FLG69356Medicare UPIN