Provider Demographics
NPI:1134124720
Name:GAVINI, VIJAYA LAKSHMI (MD)
Entity Type:Individual
Prefix:
First Name:VIJAYA
Middle Name:LAKSHMI
Last Name:GAVINI
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 1:15990 W 9 MILE RD
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48075-4826
Mailing Address - Country:US
Mailing Address - Phone:248-849-4226
Mailing Address - Fax:248-849-4240
Practice Address - Street 1:26850 PROVIDENCE PKWY
Practice Address - Street 2:402
Practice Address - City:NOVI
Practice Address - State:MI
Practice Address - Zip Code:48374-1213
Practice Address - Country:US
Practice Address - Phone:248-465-4350
Practice Address - Fax:248-465-5693
Is Sole Proprietor?:No
Enumeration Date:2005-06-20
Last Update Date:2011-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301038458207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI325412210Medicaid
MI325412210Medicaid
MI0F36022049Medicare ID - Type UnspecifiedPROVIDER ID