Provider Demographics
NPI:1235442393
Name:MUPPIDI, VIJAYADERSHAN (MD)
Entity Type:Individual
Prefix:
First Name:VIJAYADERSHAN
Middle Name:
Last Name:MUPPIDI
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 1:3000 N INTERSTATE 35
Mailing Address - Street 2:
Mailing Address - City:DENTON
Mailing Address - State:TX
Mailing Address - Zip Code:76201-5119
Mailing Address - Country:US
Mailing Address - Phone:940-898-7144
Mailing Address - Fax:
Practice Address - Street 1:3000 N INTERSTATE 35
Practice Address - Street 2:
Practice Address - City:DENTON
Practice Address - State:TX
Practice Address - Zip Code:76201-5119
Practice Address - Country:US
Practice Address - Phone:940-898-7144
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-19
Last Update Date:2021-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI60952207R00000X, 208M00000X
PAMT197390207R00000X
IN01076877A208M00000X
TXT1480207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000001037768OtherANTHEM
IN201378520Medicaid
IN000001037768OtherANTHEM