Provider Demographics
NPI:1699109181
Name:SOUTHERN VASCULAR OF PANAMA CITY PLLC
Entity type:Organization
Organization Name:SOUTHERN VASCULAR OF PANAMA CITY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ASHISH
Authorized Official - Middle Name:K
Authorized Official - Last Name:GUPTA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:850-896-1696
Mailing Address - Street 1:1399 JENKS AVE # 12
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32401-2442
Mailing Address - Country:US
Mailing Address - Phone:850-532-6303
Mailing Address - Fax:850-307-5402
Practice Address - Street 1:1399 JENKS AVE # 12
Practice Address - Street 2:
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32401-2442
Practice Address - Country:US
Practice Address - Phone:850-532-6303
Practice Address - Fax:850-307-5402
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-03
Last Update Date:2019-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL2086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL004XTOtherFLORIDA BLUE
FLDU2333OtherRAILROAD MEDICARE
FL004XTOtherFLORIDA BLUE