1073520177 NPI number — VIJAYA NAMA MD PA

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073520177 NPI number — VIJAYA NAMA MD PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
VIJAYA NAMA MD PA
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:
1073520177
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
407 W INTERSTATE 30
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GARLAND
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75043-5912
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
972-303-3000
Provider Business Mailing Address Fax Number:
972-303-3003

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
407 W INTERSTATE 30
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GARLAND
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75043-5912
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
972-303-3000
Provider Business Practice Location Address Fax Number:
972-303-3003
Provider Enumeration Date:
08/02/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
NAMA
Authorized Official First Name:
VIJAYA
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
972-303-3000

Provider Taxonomy Codes

  • Taxonomy code: 261QP2300X , with the licence number:  L7821 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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