Provider Demographics
NPI:1982772471
Name:STAMBOLIS, VASILIOS (MD)
Entity Type:Individual
Prefix:
First Name:VASILIOS
Middle Name:
Last Name:STAMBOLIS
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:PO BOX 863407
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32886-3407
Mailing Address - Country:US
Mailing Address - Phone:941-917-2600
Mailing Address - Fax:941-917-7884
Practice Address - Street 1:1700 S TAMIAMI TRL
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34239-3509
Practice Address - Country:US
Practice Address - Phone:941-917-6574
Practice Address - Fax:941-917-4278
Is Sole Proprietor?:No
Enumeration Date:2006-12-01
Last Update Date:2018-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036.065621208100000X
FLME56039208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036065621Medicaid
ILC42390Medicare UPIN
ILL67356Medicare ID - Type Unspecified
ILL67509Medicare ID - Type Unspecified