Provider Demographics
NPI:1124017249
Name:KANDIAH, VIGNESWARAN (MD)
Entity Type:Individual
Prefix:
First Name:VIGNESWARAN
Middle Name:
Last Name:KANDIAH
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 1:101 COLLEGE ST
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:NY
Mailing Address - Zip Code:13323-1634
Mailing Address - Country:US
Mailing Address - Phone:315-853-5532
Mailing Address - Fax:315-853-1003
Practice Address - Street 1:101 COLLEGE ST
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:NY
Practice Address - Zip Code:13323-1634
Practice Address - Country:US
Practice Address - Phone:315-853-5532
Practice Address - Fax:315-853-1003
Is Sole Proprietor?:No
Enumeration Date:2005-10-20
Last Update Date:2017-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY208794-1207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02099241Medicaid
NYP00048558OtherRRMCR
NY02099241Medicaid
NYP00048558OtherRRMCR