Provider Demographics
NPI:1750510723
Name:PANTHULU, VEDASHREE ENAGANDULA (MD)
Entity Type:Individual
Prefix:
First Name:VEDASHREE
Middle Name:ENAGANDULA
Last Name:PANTHULU
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:VEDASHREE
Other - Middle Name:
Other - Last Name:ENAGANDULA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:771 CYPRESS VILLAGE BLVD
Mailing Address - Street 2:
Mailing Address - City:SUN CITY CENTER
Mailing Address - State:FL
Mailing Address - Zip Code:33573-6801
Mailing Address - Country:US
Mailing Address - Phone:813-333-5080
Mailing Address - Fax:813-773-7717
Practice Address - Street 1:771 CYPRESS VILLAGE BLVD
Practice Address - Street 2:
Practice Address - City:SUN CITY CENTER
Practice Address - State:FL
Practice Address - Zip Code:33573
Practice Address - Country:US
Practice Address - Phone:813-333-5080
Practice Address - Fax:813-773-7717
Is Sole Proprietor?:No
Enumeration Date:2009-07-10
Last Update Date:2018-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME112723207R00000X, 208M00000X, 207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL006373100Medicaid
FLGK131ZMedicare UPIN
FLGK131YMedicare UPIN