Provider Demographics
NPI:1265501571
Name:MANDALAYWALA, VIJAY KUMAR S (MD)
Entity Type:Individual
Prefix:
First Name:VIJAY KUMAR
Middle Name:S
Last Name:MANDALAYWALA
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 1:17 HOSPITAL DR. , STE 5
Mailing Address - Street 2:
Mailing Address - City:MASSENA
Mailing Address - State:NY
Mailing Address - Zip Code:13662-1039
Mailing Address - Country:US
Mailing Address - Phone:315-769-4656
Mailing Address - Fax:315-769-4671
Practice Address - Street 1:17 HOSPITAL DR STE 5
Practice Address - Street 2:
Practice Address - City:MASSENA
Practice Address - State:NY
Practice Address - Zip Code:13662-1039
Practice Address - Country:US
Practice Address - Phone:315-769-4656
Practice Address - Fax:315-769-4671
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-08
Last Update Date:2011-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY157002208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY51718BMedicare ID - Type Unspecified
NYE28246Medicare UPIN