Provider Demographics
NPI:1174018642
Name:LEELARUBAN, VISHNUVENI (MD)
Entity Type:Individual
Prefix:
First Name:VISHNUVENI
Middle Name:
Last Name:LEELARUBAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:VISHNUVENI
Other - Middle Name:
Other - Last Name:KANDASAMY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:355 BARD AVE DEPT OF
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10310-1664
Mailing Address - Country:US
Mailing Address - Phone:718-818-2419
Mailing Address - Fax:
Practice Address - Street 1:725 S QUEEN ST
Practice Address - Street 2:
Practice Address - City:DOVER
Practice Address - State:DE
Practice Address - Zip Code:19904-3568
Practice Address - Country:US
Practice Address - Phone:302-678-4488
Practice Address - Fax:302-678-4497
Is Sole Proprietor?:No
Enumeration Date:2018-06-27
Last Update Date:2021-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC1-0024260207R00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program