Provider Demographics
NPI:1043278294
Name:KAMINENI, VIJAY GT (MD)
Entity Type:Individual
Prefix:
First Name:VIJAY
Middle Name:GT
Last Name:KAMINENI
Suffix:
Gender:M
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 236
Mailing Address - Street 2:
Mailing Address - City:LAGRANGE
Mailing Address - State:IN
Mailing Address - Zip Code:46761-0236
Mailing Address - Country:US
Mailing Address - Phone:260-463-2133
Mailing Address - Fax:260-463-3775
Practice Address - Street 1:2500 N DETROIT ST
Practice Address - Street 2:
Practice Address - City:LAGRANGE
Practice Address - State:IN
Practice Address - Zip Code:46761-1158
Practice Address - Country:US
Practice Address - Phone:260-463-2133
Practice Address - Fax:260-463-3775
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2024-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01061449A207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200821610Medicaid
IN070860QQMedicare PIN
IN200821610Medicaid
IN194020DMedicare ID - Type Unspecified