Provider Demographics
NPI:1992967319
Name:VATTHYAM, ROSHAN K (MD)
Entity type:Individual
Prefix:
First Name:ROSHAN
Middle Name:K
Last Name:VATTHYAM
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 2147
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33902-2147
Mailing Address - Country:US
Mailing Address - Phone:239-343-6350
Mailing Address - Fax:239-343-6358
Practice Address - Street 1:9800 S HEALTH PARK DRIVE
Practice Address - Street 2:SUITE 320
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33908-3630
Practice Address - Country:US
Practice Address - Phone:239-343-6350
Practice Address - Fax:239-343-6358
Is Sole Proprietor?:No
Enumeration Date:2008-06-26
Last Update Date:2021-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME109924207R00000X, 207RC0000X, 207RC0001X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Yes207RC0001XAllopathic & Osteopathic PhysiciansInternal MedicineClinical Cardiac Electrophysiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL003857000Medicaid
IN000000614311OtherANTHEM BCBS
IN200938050Medicaid
INM400015125Medicare PIN