Provider Demographics
NPI:1629048244
Name:LYSANDER, VIMALESH (MD)
Entity Type:Individual
Prefix:
First Name:VIMALESH
Middle Name:
Last Name:LYSANDER
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 65274
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28265-0274
Mailing Address - Country:US
Mailing Address - Phone:800-377-8721
Mailing Address - Fax:304-523-2241
Practice Address - Street 1:1950 MOUNT SAINT MARYS DR
Practice Address - Street 2:
Practice Address - City:NELSONVILLE
Practice Address - State:OH
Practice Address - Zip Code:45764-1280
Practice Address - Country:US
Practice Address - Phone:740-753-1931
Practice Address - Fax:740-753-3177
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-25
Last Update Date:2013-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-06-2837-L207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0893298Medicaid
OH5619197341A48OtherBLUECROSS BLUESHIELD
F37423Medicare UPIN
OH5619197341A48OtherBLUECROSS BLUESHIELD