Provider Demographics
NPI:1720387244
Name:PANDURANGAN, LATHA (MD)
Entity Type:Individual
Prefix:DR
First Name:LATHA
Middle Name:
Last Name:PANDURANGAN
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 1:180 PATRICIA AVE
Mailing Address - Street 2:
Mailing Address - City:DUNEDIN
Mailing Address - State:FL
Mailing Address - Zip Code:34698-8103
Mailing Address - Country:US
Mailing Address - Phone:727-733-4193
Mailing Address - Fax:813-635-2638
Practice Address - Street 1:180 PATRICIA AVE
Practice Address - Street 2:
Practice Address - City:DUNEDIN
Practice Address - State:FL
Practice Address - Zip Code:34698-8103
Practice Address - Country:US
Practice Address - Phone:727-733-4193
Practice Address - Fax:813-635-2638
Is Sole Proprietor?:No
Enumeration Date:2011-03-23
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME117760207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLP01375021OtherMEDICARE RAILROAD PROVIDER NUMBER
FL012839400Medicaid
FLP01375021OtherMEDICARE RAILROAD PROVIDER NUMBER