Provider Demographics
NPI:1275518581
Name:GOBURDHUN, VIJAY (MD)
Entity Type:Individual
Prefix:DR
First Name:VIJAY
Middle Name:
Last Name:GOBURDHUN
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 1:14555 LEVAN RD STE 310
Mailing Address - Street 2:
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48154-5085
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:14555 LEVAN RD STE 403
Practice Address - Street 2:
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48154-5085
Practice Address - Country:US
Practice Address - Phone:734-655-1618
Practice Address - Fax:734-462-5997
Is Sole Proprietor?:No
Enumeration Date:2005-12-08
Last Update Date:2018-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301031529207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1057661Medicaid
MI1128215312OtherBLUE CROSS PROVIDER NO
MIVG031529OtherSTATE LICENSE
MIVG031529OtherSTATE LICENSE
MI2821531Medicare ID - Type Unspecified