Provider Demographics
NPI:1477749224
Name:SUN STATE MEDICAL GROUP INC
Entity Type:Organization
Organization Name:SUN STATE MEDICAL GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:VICTOR
Authorized Official - Middle Name:RAGU
Authorized Official - Last Name:ROBERTS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:407-427-4906
Mailing Address - Street 1:1403 MEDICAL PLAZA DR
Mailing Address - Street 2:SUITE 207
Mailing Address - City:SANFORD
Mailing Address - State:FL
Mailing Address - Zip Code:32771-1000
Mailing Address - Country:US
Mailing Address - Phone:407-365-6722
Mailing Address - Fax:
Practice Address - Street 1:1403 MEDICAL PLAZA DR
Practice Address - Street 2:SUITE 207
Practice Address - City:SANFORD
Practice Address - State:FL
Practice Address - Zip Code:32771-1000
Practice Address - Country:US
Practice Address - Phone:407-365-6722
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-14
Last Update Date:2009-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME88739207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK6973Medicare PIN
FLI01333Medicare UPIN
FLU1869YMedicare PIN