Provider Demographics
NPI:1033177522
Name:PATRICK, VIJAYALAKSHMY (MD)
Entity Type:Individual
Prefix:
First Name:VIJAYALAKSHMY
Middle Name:
Last Name:PATRICK
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 1:3551 RGER BROOKE DR
Mailing Address - Street 2:JBSA FORT SAM HOUSTON
Mailing Address - City:FORT SAM HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:78234
Mailing Address - Country:US
Mailing Address - Phone:210-539-9567
Mailing Address - Fax:210-539-5467
Practice Address - Street 1:5664 SW 60TH AVENUE
Practice Address - Street 2:
Practice Address - City:OCALA
Practice Address - State:FL
Practice Address - Zip Code:34474-5677
Practice Address - Country:US
Practice Address - Phone:352-291-5400
Practice Address - Fax:352-291-5582
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2018-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME910092084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL272180500Medicaid
79622OtherCIGNA BEHAVIORAL HEALTH
FL50331OtherBLUE CROSS BLUE SHIELD
U3842AMedicare ID - Type Unspecified
FL272180500Medicaid