Provider Demographics
NPI:1245213222
Name:KOLI, VIJAY N (MD)
Entity Type:Individual
Prefix:DR
First Name:VIJAY
Middle Name:N
Last Name:KOLI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:102 PALO ALTO RD
Mailing Address - Street 2:300
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78211-3791
Mailing Address - Country:US
Mailing Address - Phone:210-924-5097
Mailing Address - Fax:210-924-1116
Practice Address - Street 1:102 PALO ALTO RD
Practice Address - Street 2:300
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78211-3791
Practice Address - Country:US
Practice Address - Phone:210-924-5097
Practice Address - Fax:210-924-1116
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-23
Last Update Date:2016-07-05
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXF3197207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX120291303Medicaid
TXC18006Medicare UPIN
TX00HR33Medicare ID - Type Unspecified