Provider Demographics
NPI:1467441790
Name:NAGABHAIRU, VIJAYA L (MD)
Entity Type:Individual
Prefix:
First Name:VIJAYA
Middle Name:L
Last Name:NAGABHAIRU
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 1:39 E ATWATER AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:EUSTIS
Mailing Address - State:FL
Mailing Address - Zip Code:32726-5540
Mailing Address - Country:US
Mailing Address - Phone:352-483-0900
Mailing Address - Fax:
Practice Address - Street 1:212 S FLORIDA ST
Practice Address - Street 2:
Practice Address - City:BUSHNELL
Practice Address - State:FL
Practice Address - Zip Code:33513-6703
Practice Address - Country:US
Practice Address - Phone:352-793-2441
Practice Address - Fax:352-793-3282
Is Sole Proprietor?:No
Enumeration Date:2005-10-19
Last Update Date:2017-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME89894207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL274016800Medicaid
FLI46196Medicare UPIN
FL274016800Medicaid