1558547422 NPI number — VIJAK AYASANONDA MD LLC

Table of content: (NPI 1558547422)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558547422 NPI number — VIJAK AYASANONDA MD LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
VIJAK AYASANONDA MD LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1558547422
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/24/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3916 STATE ST
Provider Second Line Business Mailing Address:
#300
Provider Business Mailing Address City Name:
SANTA BARBARA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
93105-5602
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
805-563-3011
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
221 MAHALANI ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WAILUKU
Provider Business Practice Location Address State Name:
HI
Provider Business Practice Location Address Postal Code:
96793-2526
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
808-242-2290
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/10/2008

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
AYASANONDA
Authorized Official First Name:
VIJAK
Authorized Official Middle Name:
S.
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
808-589-1391

Provider Taxonomy Codes

  • Taxonomy code: 207P00000X , with the licence number:  MD-13293 , registered in the state of HI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)