1891996880 NPI number — VINOD R MIRYALA MD

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1891996880 NPI number — VINOD R MIRYALA MD

Employer Identification Number (EIN):

Provider Organization Name:

Provider Last Name:

MIRYALA

Provider First Name:

VINOD

Provider Middle Name:

R

Provider Name Prefix Text:

Provider Name Suffix Text:

Provider Credential Text:

MD

Provider Gender Code:

M

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:

1891996880

Entity Type Code:

Individual

Replacement NPI:

Last Update Date:

10/11/2023

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

Provider First Line Business Mailing Address:

308 W HIGHLAND BLVD

Provider Second Line Business Mailing Address:

Provider Business Mailing Address City Name:

INVERNESS

Provider Business Mailing Address State Name:

FL

Provider Business Mailing Address Postal Code:

34452-4716

Provider Business Mailing Address Country Code:

US

Provider Business Mailing Address Telephone Number:

352-726-8353

Provider Business Mailing Address Fax Number:

352-726-5038

Provider First Line Business Practice Location Address:

910 OLD CAMP RD

Provider Second Line Business Practice Location Address:

BLDG 210

Provider Business Practice Location Address City Name:

THE VILLAGES

Provider Business Practice Location Address State Name:

FL

Provider Business Practice Location Address Postal Code:

32162-5604

Provider Business Practice Location Address Country Code:

US

Provider Business Practice Location Address Telephone Number:

352-751-3356

Provider Business Practice Location Address Fax Number:

352-751-3359

Provider Enumeration Date:

05/29/2007

Authorized Official Last Name:

Authorized Official First Name:

Authorized Official Middle Name:

Authorized Official Title or Position:

Authorized Official Telephone Number:

• Taxonomy code: 207RC0000X , with the licence number:  ME75516 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

• Identifier: 43462 . This is a "BCBS OF FL" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
• Identifier: 77940 . This is a "BCBS OF FL GROUP ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
• Identifier: ME75516 . This is a "STATE MEDICAL LICENSE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
• Identifier: 269859500 . This is a "MEDICAID GROUP" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
• Identifier: CF1416 . This is a "MEDICARE RR GROUP" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
• Identifier: P00455415 . This is a "MEDICARE RR" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
• Identifier: 254028200 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
• Identifier: 10715924 . This is a "CAQH" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
• Identifier: 7390633 . This is a "CIGNA" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
• Identifier: 77940 . This is a "MEDICARE GROUP ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
• Identifier: 254028200 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".