Provider Demographics
NPI:1164662508
Name:AMMISETTY, VIJAYA RAMA (M D)
Entity Type:Individual
Prefix:
First Name:VIJAYA
Middle Name:RAMA
Last Name:AMMISETTY
Suffix:
Gender:F
Credentials:M D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 910
Mailing Address - Street 2:
Mailing Address - City:MARTIN
Mailing Address - State:KY
Mailing Address - Zip Code:41649-0910
Mailing Address - Country:US
Mailing Address - Phone:606-285-6400
Mailing Address - Fax:
Practice Address - Street 1:11203 MAIN STREET
Practice Address - Street 2:
Practice Address - City:MARTIN
Practice Address - State:KY
Practice Address - Zip Code:41649-0910
Practice Address - Country:US
Practice Address - Phone:606-285-6400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-02-25
Last Update Date:2010-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY42400207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY0975102Medicare Oscar/Certification