Basic Information
| Provider Information | |||||||||
| NPI: | 1649412099 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VANGALA | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | KAVITHA | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 9430 TURKEY LAKE RD STE 110 | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328198015 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3218417856 | ||||||||
| FaxNumber: | 3218436432 | ||||||||
| Practice Location | |||||||||
| Address1: | 9430 TURKEY LAKE RD STE 110 | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328198015 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3218417856 | ||||||||
| FaxNumber: | 3218436432 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/01/2009 | ||||||||
| LastUpdateDate: | 01/05/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 01/05/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0200X | ME107710 | FL | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine | 207RP1001X | ME107710 | FL | N | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease |
ID Information
| ID | Type | State | Issuer | Description | 002912400 | 05 | FL | MEDICAID | ME107710 | 01 | FL | MEDICAL LICENSE | OTHER |