Provider Demographics
NPI:1356474415
Name:DR. VIJAY PETHKAR MD PLLC
Entity Type:Organization
Organization Name:DR. VIJAY PETHKAR MD PLLC
Other - Org Name:VIJAY PETHKAR MD PLLC
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:VIJAY
Authorized Official - Middle Name:
Authorized Official - Last Name:PETHKAR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:615-727-1963
Mailing Address - Street 1:780 N MOUNT JULIET RD
Mailing Address - Street 2:
Mailing Address - City:MOUNT JULIET
Mailing Address - State:TN
Mailing Address - Zip Code:37122-3323
Mailing Address - Country:US
Mailing Address - Phone:615-758-9273
Mailing Address - Fax:615-758-4821
Practice Address - Street 1:780 N MOUNT JULIET RD
Practice Address - Street 2:
Practice Address - City:MOUNT JULIET
Practice Address - State:TN
Practice Address - Zip Code:37122-3323
Practice Address - Country:US
Practice Address - Phone:615-758-9273
Practice Address - Fax:615-758-4821
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-14
Last Update Date:2023-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD31687207RP1001X, 261QS1200X
MD31687207RS0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Multi-Specialty
No207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep MedicineGroup - Multi-Specialty
No261QS1200XAmbulatory Health Care FacilitiesClinic/CenterSleep Disorder DiagnosticGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3729715Medicaid
TN3729715Medicare ID - Type UnspecifiedGROUP MEDICARE NUMBER