Provider Demographics
NPI:1649289059
Name:SOOSAIPILLAI, IVAN (MD)
Entity type:Individual
Prefix:
First Name:IVAN
Middle Name:
Last Name:SOOSAIPILLAI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3306 SW 26TH AVE
Mailing Address - Street 2:SUITE 104
Mailing Address - City:OCALA
Mailing Address - State:FL
Mailing Address - Zip Code:34471-7856
Mailing Address - Country:US
Mailing Address - Phone:352-622-2020
Mailing Address - Fax:352-622-2025
Practice Address - Street 1:3306 SW 26TH AVE
Practice Address - Street 2:SUITE 104
Practice Address - City:OCALA
Practice Address - State:FL
Practice Address - Zip Code:34471-7856
Practice Address - Country:US
Practice Address - Phone:352-622-2020
Practice Address - Fax:352-622-2025
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-05
Last Update Date:2011-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME95964207R00000X, 207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL56424OtherBCBS
FL279943000Medicaid
FLP00750221OtherRR MEDICARE
FL56424OtherBCBS