Provider Demographics
NPI:1407019037
Name:VYAKARANAM, SUDHIR BHARGAV (MD)
Entity Type:Individual
Prefix:DR
First Name:SUDHIR
Middle Name:BHARGAV
Last Name:VYAKARANAM
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:PO BOX 5909
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97228-5909
Mailing Address - Country:US
Mailing Address - Phone:574-273-6767
Mailing Address - Fax:574-968-7160
Practice Address - Street 1:710 PARK PL
Practice Address - Street 2:
Practice Address - City:MISHAWAKA
Practice Address - State:IN
Practice Address - Zip Code:46545-3519
Practice Address - Country:US
Practice Address - Phone:574-273-6767
Practice Address - Fax:574-968-7160
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-03
Last Update Date:2020-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMT 187877207R00000X
OH35095420207R00000X
IN01069102A207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201018440Medicaid
INM400046988Medicare PIN