Provider Demographics
NPI:1376537308
Name:BROUMAND, VADJISTA (MD)
Entity Type:Individual
Prefix:
First Name:VADJISTA
Middle Name:
Last Name:BROUMAND
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4110 MEDICAL CENTER DR
Mailing Address - Street 2:SUITE 110
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:13066
Mailing Address - Country:US
Mailing Address - Phone:315-663-0100
Mailing Address - Fax:315-663-0052
Practice Address - Street 1:4110 MEDICAL CENTER DR
Practice Address - Street 2:SUITE 110
Practice Address - City:FAYETTEVILLE
Practice Address - State:NY
Practice Address - Zip Code:13066
Practice Address - Country:US
Practice Address - Phone:315-663-0100
Practice Address - Fax:315-663-0052
Is Sole Proprietor?:No
Enumeration Date:2005-09-06
Last Update Date:2014-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY235818207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine