Provider Demographics
NPI:1568522233
Name:BOGAVELLI, VIJAYALAXMI (MD)
Entity Type:Individual
Prefix:DR
First Name:VIJAYALAXMI
Middle Name:
Last Name:BOGAVELLI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:VIJAYALAXMI
Other - Middle Name:
Other - Last Name:JUVVADI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 3158
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3158
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9155 SW BARNES RD
Practice Address - Street 2:STE 333
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97225-6625
Practice Address - Country:US
Practice Address - Phone:503-216-5102
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-11
Last Update Date:2021-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD1662662084P0804X, 2084P0800X
NC95-011782084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500686948Medicaid
NC5901479Medicaid
ORR183510Medicare PIN