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
StateLicense IDTaxonomies
NMMD2018-0900208M00000X
NV10842208M00000X
UT7792753-1205208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ468247Medicaid
NV100503526Medicaid
AZ468247Medicaid
NV39508Medicare ID - Type UnspecifiedNORIDIAN
NV100503526Medicaid