Provider Demographics
NPI:1598715765
Name:CHANNAMSETTY, VIJAYASIMHAM (MD)
Entity Type:Individual
Prefix:DR
First Name:VIJAYASIMHAM
Middle Name:
Last Name:CHANNAMSETTY
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 1:60 EAST ST STE 1400
Mailing Address - Street 2:
Mailing Address - City:METHUEN
Mailing Address - State:MA
Mailing Address - Zip Code:01844-4550
Mailing Address - Country:US
Mailing Address - Phone:978-689-4601
Mailing Address - Fax:
Practice Address - Street 1:295 VARNUM AVE
Practice Address - Street 2:
Practice Address - City:LOWELL
Practice Address - State:MA
Practice Address - Zip Code:01854
Practice Address - Country:US
Practice Address - Phone:978-937-6235
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-11
Last Update Date:2018-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA41465207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2069458Medicaid
MAB26235Medicare ID - Type UnspecifiedMASSACHUSETTS MEDICARE
MA2069458Medicaid