Provider Demographics
NPI:1790091692
Name:O SAMBANDAM MD PA
Entity Type:Organization
Organization Name:O SAMBANDAM MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:O
Authorized Official - Middle Name:
Authorized Official - Last Name:SAMBANDAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD PA
Authorized Official - Phone:941-627-0323
Mailing Address - Street 1:2400 HARBOR BLVD
Mailing Address - Street 2:SUITE 8
Mailing Address - City:PORT CHARLOTTE
Mailing Address - State:FL
Mailing Address - Zip Code:33952-5052
Mailing Address - Country:US
Mailing Address - Phone:941-627-0323
Mailing Address - Fax:941-627-3853
Practice Address - Street 1:2400 HARBOR BLVD
Practice Address - Street 2:SUITE 8
Practice Address - City:PORT CHARLOTTE
Practice Address - State:FL
Practice Address - Zip Code:33952-5052
Practice Address - Country:US
Practice Address - Phone:941-627-0323
Practice Address - Fax:941-627-3853
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-30
Last Update Date:2010-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME33947207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLO39846200Medicaid