Provider Demographics
NPI:1083727333
Name:MAHADEVAN, VIJAYABHANU (MD)
Entity Type:Individual
Prefix:DR
First Name:VIJAYABHANU
Middle Name:
Last Name:MAHADEVAN
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 1:12665 W SMOKEY DR # 140
Mailing Address - Street 2:#140
Mailing Address - City:SURPRISE
Mailing Address - State:AZ
Mailing Address - Zip Code:85378-3703
Mailing Address - Country:US
Mailing Address - Phone:623-219-4040
Mailing Address - Fax:623-219-4050
Practice Address - Street 1:12665 W SMOKEY DR # 140
Practice Address - Street 2:#140
Practice Address - City:SURPRISE
Practice Address - State:AZ
Practice Address - Zip Code:85378-3703
Practice Address - Country:US
Practice Address - Phone:623-219-4040
Practice Address - Fax:623-219-4050
Is Sole Proprietor?:No
Enumeration Date:2006-08-17
Last Update Date:2023-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101230340207RR0500X
AZ37475207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ260994Medicaid
AZ2118901Medicare PIN
AZG95304Medicare UPIN
AZ260994Medicaid
G95304Medicare UPIN