Provider Demographics
NPI:1528015187
Name:PURAM, VIJAYALAKSHMI (MD)
Entity Type:Individual
Prefix:
First Name:VIJAYALAKSHMI
Middle Name:
Last Name:PURAM
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:PO BOX 2917
Mailing Address - Street 2:
Mailing Address - City:PIKEVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:41502-2917
Mailing Address - Country:US
Mailing Address - Phone:606-218-3925
Mailing Address - Fax:
Practice Address - Street 1:172 S MAYO TRL
Practice Address - Street 2:
Practice Address - City:PIKEVILLE
Practice Address - State:KY
Practice Address - Zip Code:41501-1515
Practice Address - Country:US
Practice Address - Phone:606-218-4742
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-28
Last Update Date:2012-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY27968207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64279680Medicaid
KY3313685Medicare PIN
KY64279680Medicaid