Provider Demographics
NPI:1568400901
Name:JEFFERSON MED-PEDS INC
Entity Type:Organization
Organization Name:JEFFERSON MED-PEDS INC
Other - Org Name:VIKRAM DAYAL, MD
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:VIKRAM
Authorized Official - Middle Name:
Authorized Official - Last Name:DAYAL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:304-279-1372
Mailing Address - Street 1:207 E 5TH AVE
Mailing Address - Street 2:
Mailing Address - City:RANSON
Mailing Address - State:WV
Mailing Address - Zip Code:25438-1613
Mailing Address - Country:US
Mailing Address - Phone:304-279-1372
Mailing Address - Fax:
Practice Address - Street 1:207 E 5TH AVE
Practice Address - Street 2:
Practice Address - City:RANSON
Practice Address - State:WV
Practice Address - Zip Code:25438-1613
Practice Address - Country:US
Practice Address - Phone:304-279-1372
Practice Address - Fax:304-728-3623
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-04
Last Update Date:2012-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV16223207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0073128000Medicaid
WV0073128000Medicaid