Provider Demographics
NPI:1275514903
Name:VIJAYANAGAR, RAGHAVENDRA R (MD)
Entity Type:Individual
Prefix:DR
First Name:RAGHAVENDRA
Middle Name:R
Last Name:VIJAYANAGAR
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 1:5 TAMPA GENERAL CIR STE 855
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33606-3601
Mailing Address - Country:US
Mailing Address - Phone:813-251-8600
Mailing Address - Fax:813-251-8677
Practice Address - Street 1:5 TAMPA GENERAL CIR STE 855
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33606-3601
Practice Address - Country:US
Practice Address - Phone:813-251-8600
Practice Address - Fax:813-251-8677
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-09
Last Update Date:2022-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0021413174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL055937700Medicaid
FL055937700Medicaid
FL29755ZMedicare ID - Type UnspecifiedMEDICARE ID NUMBER