Provider Demographics
NPI:1770548679
Name:IYENGAR, VASUNDHARA G (M D)
Entity type:Individual
Prefix:
First Name:VASUNDHARA
Middle Name:G
Last Name:IYENGAR
Suffix:
Gender:F
Credentials:M D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4371 VERONICA S SHOEMAKER BLVD
Mailing Address - Street 2:ATTN: CREDENTIAL DEPARTMENT
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33916-2216
Mailing Address - Country:US
Mailing Address - Phone:239-274-8200
Mailing Address - Fax:239-278-3350
Practice Address - Street 1:1920 DON WICKHAM DR STE 100
Practice Address - Street 2:
Practice Address - City:CLERMONT
Practice Address - State:FL
Practice Address - Zip Code:34711-1977
Practice Address - Country:US
Practice Address - Phone:352-394-1150
Practice Address - Fax:352-394-1560
Is Sole Proprietor?:No
Enumeration Date:2006-04-20
Last Update Date:2021-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0044726207RH0000X, 207RX0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
No207RH0000XAllopathic & Osteopathic PhysiciansInternal MedicineHematology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL040458600Medicaid
FL040458600Medicaid
FL03831Medicare ID - Type Unspecified
FL03831WMedicare UPIN
FL03831VMedicare PIN
FLP00965117OtherRR MEDICARE