Provider Demographics
NPI:1366575292
Name:SOUTHWEST FLORIDA ENDOSCOPY
Entity type:Organization
Organization Name:SOUTHWEST FLORIDA ENDOSCOPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JANSI
Authorized Official - Middle Name:R
Authorized Official - Last Name:PRABAKARAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:239-275-6678
Mailing Address - Street 1:5050 MASON CORBIN CT
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33907-4541
Mailing Address - Country:US
Mailing Address - Phone:239-275-6678
Mailing Address - Fax:
Practice Address - Street 1:5050 MASON CORBIN CT
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33907-4541
Practice Address - Country:US
Practice Address - Phone:239-275-6678
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLF1095Medicare ID - Type Unspecified