Provider Demographics
NPI:1811286693
Name:POTTACKAL, SANGY PAUL (MD)
Entity type:Individual
Prefix:DR
First Name:SANGY
Middle Name:PAUL
Last Name:POTTACKAL
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 1:2700 UNIVERSITY SQUARE DR
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33612-5513
Mailing Address - Country:US
Mailing Address - Phone:813-253-2721
Mailing Address - Fax:813-977-3720
Practice Address - Street 1:12901 BRUCE B DOWNS BLVD
Practice Address - Street 2:MDC 41
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33612-4742
Practice Address - Country:US
Practice Address - Phone:813-974-3680
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-04-01
Last Update Date:2017-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
FLME1275952085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program