Basic Information
| Provider Information | |||||||||
| NPI: | 1992967319 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VATTHYAM | ||||||||
| FirstName: | ROSHAN | ||||||||
| MiddleName: | K | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2147 | ||||||||
| Address2: | |||||||||
| City: | FORT MYERS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339022147 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2393436350 | ||||||||
| FaxNumber: | 2393436358 | ||||||||
| Practice Location | |||||||||
| Address1: | 9800 S HEALTH PARK DRIVE | ||||||||
| Address2: | SUITE 320 | ||||||||
| City: | FORT MYERS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339083630 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2393436350 | ||||||||
| FaxNumber: | 2393436358 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/26/2008 | ||||||||
| LastUpdateDate: | 03/30/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/30/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | ME109924 | FL | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RC0000X | ME109924 | FL | N | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207RC0001X | ME109924 | FL | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Clinical Cardiac Electrophysiology |
ID Information
| ID | Type | State | Issuer | Description | 003857000 | 05 | FL | MEDICAID | 000000614311 | 01 | IN | ANTHEM BCBS | OTHER | 200938050 | 05 | IN | MEDICAID |