Provider Demographics
NPI:1326669060
Name:KUPPURAJAN, VIJAY KRISHNA
Entity Type:Individual
Prefix:
First Name:VIJAY
Middle Name:KRISHNA
Last Name:KUPPURAJAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:707 PALM AVE
Mailing Address - Street 2:
Mailing Address - City:IMPERIAL BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:91932-1229
Mailing Address - Country:US
Mailing Address - Phone:619-429-7700
Mailing Address - Fax:
Practice Address - Street 1:707 PALM AVE
Practice Address - Street 2:
Practice Address - City:IMPERIAL BEACH
Practice Address - State:CA
Practice Address - Zip Code:91932-1229
Practice Address - Country:US
Practice Address - Phone:619-429-7700
Practice Address - Fax:619-429-7703
Is Sole Proprietor?:No
Enumeration Date:2020-05-05
Last Update Date:2023-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA183031207R00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine