Provider Demographics
NPI:1093493355
Name:NETHALA, VIJAY SAM (MBBS)
Entity Type:Individual
Prefix:
First Name:VIJAY SAM
Middle Name:
Last Name:NETHALA
Suffix:
Gender:M
Credentials:MBBS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8323 N SHANNON RD
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85742-9597
Mailing Address - Country:US
Mailing Address - Phone:703-966-4293
Mailing Address - Fax:
Practice Address - Street 1:6200 N LA CHOLLA BLVD
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85741-3529
Practice Address - Country:US
Practice Address - Phone:575-386-9110
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-07
Last Update Date:2023-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZR80442390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program