Provider Demographics
NPI:1376745935
Name:VIJAYAPPA, MADHU B (MD)
Entity Type:Individual
Prefix:DR
First Name:MADHU
Middle Name:B
Last Name:VIJAYAPPA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:MADHU
Other - Middle Name:
Other - Last Name:BUKKASAGARA VIJAYAPPA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:1702 UNIVERSITY DR S
Mailing Address - Street 2:SSC - MEDICAL STAFF SERVICES
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-4940
Mailing Address - Country:US
Mailing Address - Phone:701-364-8177
Mailing Address - Fax:
Practice Address - Street 1:8984 SW 64TH LN
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32608-8562
Practice Address - Country:US
Practice Address - Phone:617-304-5318
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-04
Last Update Date:2023-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND139542084V0102X
AL45967208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No2084V0102XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyVascular Neurology