Provider Demographics
NPI:1902173529
Name:ROXANN SANGIACOMO, M.D., P.A.
Entity Type:Organization
Organization Name:ROXANN SANGIACOMO, M.D., P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:DONNA
Authorized Official - Middle Name:
Authorized Official - Last Name:FERRES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:239-768-6060
Mailing Address - Street 1:14150 METROPOLIS AVE
Mailing Address - Street 2:# 4
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33912-4345
Mailing Address - Country:US
Mailing Address - Phone:239-768-6060
Mailing Address - Fax:239-768-6242
Practice Address - Street 1:14150 METROPOLIS AVE
Practice Address - Street 2:# 4
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33912-4345
Practice Address - Country:US
Practice Address - Phone:239-768-6060
Practice Address - Fax:239-768-6242
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-28
Last Update Date:2014-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME00569442084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLE54355Medicare UPIN