Provider Demographics
NPI:1477594604
Name:VITTAL, BAILEY V SUDINDRA (MD)
Entity Type:Individual
Prefix:
First Name:BAILEY V
Middle Name:SUDINDRA
Last Name:VITTAL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:SUDIN
Other - Middle Name:
Other - Last Name:VITTAL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:150 N JACKSON AVENUE
Mailing Address - Street 2:SUITE 107
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95116-1908
Mailing Address - Country:US
Mailing Address - Phone:408-926-2182
Mailing Address - Fax:408-926-8370
Practice Address - Street 1:150 N JACKSON AVENUE
Practice Address - Street 2:SUITE 107
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95116-1908
Practice Address - Country:US
Practice Address - Phone:408-926-2182
Practice Address - Fax:408-926-8370
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA25286207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A252860Medicaid
CA00A252860Medicaid
00A252860Medicare ID - Type Unspecified