Provider Demographics
NPI:1326077074
Name:ADYANTHAYA, AJIT V (MD)
Entity Type:Individual
Prefix:
First Name:AJIT
Middle Name:V
Last Name:ADYANTHAYA
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 1:530 ORCHARD ST
Mailing Address - Street 2:
Mailing Address - City:WEBSTER
Mailing Address - State:TX
Mailing Address - Zip Code:77598-4110
Mailing Address - Country:US
Mailing Address - Phone:281-338-4004
Mailing Address - Fax:281-332-6524
Practice Address - Street 1:530 ORCHARD ST
Practice Address - Street 2:
Practice Address - City:WEBSTER
Practice Address - State:TX
Practice Address - Zip Code:77598-4110
Practice Address - Country:US
Practice Address - Phone:281-338-4004
Practice Address - Fax:281-332-6524
Is Sole Proprietor?:No
Enumeration Date:2006-07-02
Last Update Date:2009-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE1487207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8G2118OtherBLUE CROSS BLUE SHIELD
TX00828FOtherBLUE CROSS BLUE SHIELD
TX131261301Medicaid
TX131261307Medicaid
TX131261301Medicaid
TX8G2118OtherBLUE CROSS BLUE SHIELD
TX131261307Medicaid