Provider Demographics
NPI:1538124680
Name:PHADE, VIJAYKUMAR R (MD)
Entity Type:Individual
Prefix:
First Name:VIJAYKUMAR
Middle Name:R
Last Name:PHADE
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 1553
Mailing Address - Street 2:
Mailing Address - City:BLUEFIELD
Mailing Address - State:WV
Mailing Address - Zip Code:24701
Mailing Address - Country:US
Mailing Address - Phone:304-327-7476
Mailing Address - Fax:304-327-7476
Practice Address - Street 1:496 CHERRY ST
Practice Address - Street 2:BLDG C STE A
Practice Address - City:BLUEFIELD
Practice Address - State:WV
Practice Address - Zip Code:24701-3304
Practice Address - Country:US
Practice Address - Phone:304-327-7476
Practice Address - Fax:304-327-7476
Is Sole Proprietor?:No
Enumeration Date:2006-04-20
Last Update Date:2008-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV12519208600000X
VA0101037661208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0218227000Medicaid
WVPH0488881Medicare PIN
WVD91213Medicare UPIN