Provider Demographics
NPI: | 1205838844 |
---|---|
Name: | LINGEGOWDA, VIJAYKUMAR (MD) |
Entity Type: | Individual |
Prefix: | MR |
First Name: | VIJAYKUMAR |
Middle Name: | |
Last Name: | LINGEGOWDA |
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: | PO BOX 1249 |
Mailing Address - Street 2: | |
Mailing Address - City: | BOUNTIFUL |
Mailing Address - State: | UT |
Mailing Address - Zip Code: | 84011-1249 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 801-673-7661 |
Mailing Address - Fax: | 801-951-2389 |
Practice Address - Street 1: | 1200 EAST 3900 S |
Practice Address - Street 2: | SUITE 4B |
Practice Address - City: | SALT LAKE CITY |
Practice Address - State: | UT |
Practice Address - Zip Code: | 84124 |
Practice Address - Country: | US |
Practice Address - Phone: | 866-500-7071 |
Practice Address - Fax: | 866-500-7081 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2005-08-12 |
Last Update Date: | 2020-11-19 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
NM | MD2018-0900 | 208M00000X |
NV | 10842 | 208M00000X |
UT | 7792753-1205 | 208M00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 208M00000X | Allopathic & Osteopathic Physicians | Hospitalist |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
AZ | 468247 | Medicaid | |
NV | 100503526 | Medicaid | |
AZ | 468247 | Medicaid | |
NV | 39508 | Medicare ID - Type Unspecified | NORIDIAN |
NV | 100503526 | Medicaid |