Basic Information
| Provider Information | |||||||||
| NPI: | 1255320545 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SIRAGUSA | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | JOHN | ||||||||
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| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1900 HARRISON AVE | ||||||||
| Address2: | |||||||||
| City: | PANAMA CITY | ||||||||
| State: | FL | ||||||||
| PostalCode: | 324054542 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8507691668 | ||||||||
| FaxNumber: | 8507852123 | ||||||||
| Practice Location | |||||||||
| Address1: | 1900 HARRISON AVE | ||||||||
| Address2: | |||||||||
| City: | PANAMA CITY | ||||||||
| State: | FL | ||||||||
| PostalCode: | 324054542 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8507691668 | ||||||||
| FaxNumber: | 8507852123 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/19/2005 | ||||||||
| LastUpdateDate: | 07/23/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207N00000X | ME 23244 | FL | Y | Allopathic & Osteopathic Physicians | Dermatology |
ID Information
| ID | Type | State | Issuer | Description | 99500 | 01 | BCBS | OTHER |