Provider Demographics
NPI:1003843574
Name:VIJAYALAKSHMI, BANGALORE S (MD)
Entity Type:Individual
Prefix:
First Name:BANGALORE
Middle Name:S
Last Name:VIJAYALAKSHMI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 6001
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58108-6001
Mailing Address - Country:US
Mailing Address - Phone:701-364-3300
Mailing Address - Fax:701-364-8906
Practice Address - Street 1:1702 UNIVERSITY DR S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-4940
Practice Address - Country:US
Practice Address - Phone:701-364-3300
Practice Address - Fax:701-364-8906
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2011-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND9837208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND2265220OtherAMERICA'S PPO/ARAZ #
ND137123OtherUCARE #
NDDA9011042827OtherPREFERRED ONE #
NDHP48628OtherHEALTHPARTNERS #
ND25030OtherNDBS #
ND363627500Medicaid
ND2300320OtherMEDICA #
ND927S3VIOtherMNBS #
ND13283Medicaid
ND2300322OtherMEDICA #
ND38107OtherLHS #
ND38107OtherLHS #
ND25030OtherNDBS #
NDP00212896Medicare ID - Type UnspecifiedRR MEDICARE #