Provider Demographics
NPI:1679298665
Name:VEGESANA, SRINIVASARAJU
Entity Type:Individual
Prefix:
First Name:SRINIVASARAJU
Middle Name:
Last Name:VEGESANA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5190 CONWAY RD
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32812-1252
Mailing Address - Country:US
Mailing Address - Phone:407-851-2140
Mailing Address - Fax:
Practice Address - Street 1:5190 CONWAY RD
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32812-1252
Practice Address - Country:US
Practice Address - Phone:407-851-2140
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-11
Last Update Date:2022-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS37587183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist