1063936854 NPI number — DR. VIGHNESH VETRIVEL VENKATASAMY M.D

Table of content: DR. VIGHNESH VETRIVEL VENKATASAMY M.D (NPI 1063936854)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063936854 NPI number — DR. VIGHNESH VETRIVEL VENKATASAMY M.D

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VETRIVEL VENKATASAMY
Provider First Name:
VIGHNESH
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D
Provider Gender Code:
M

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:
1063936854
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
11/20/2018
NPI Reactivation Date:
01/31/2019

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
31 SE 5TH ST APT 903
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MIAMI
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33131-2506
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
305-753-9644
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
MIAMI TRANSPLANT INSTITUTE, JACKSON MEMORIAL HOSPITAL
Provider Second Line Business Practice Location Address:
1611 NW 12 AVENUE
Provider Business Practice Location Address City Name:
MIAMI
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33136
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
305-355-5000
Provider Business Practice Location Address Fax Number:
305-355-5797
Provider Enumeration Date:
08/02/2017

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 204F00000X , with the licence number:  ME145936 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 108329500 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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