Provider Demographics
NPI:1659378008
Name:PRAVEEN, VIJAYAKUMAR (MD)
Entity Type:Individual
Prefix:
First Name:VIJAYAKUMAR
Middle Name:
Last Name:PRAVEEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4351 E LOHMAN AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88011-8259
Mailing Address - Country:US
Mailing Address - Phone:575-532-9077
Mailing Address - Fax:575-532-9221
Practice Address - Street 1:4351 E LOHMAN AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88011-8259
Practice Address - Country:US
Practice Address - Phone:575-532-9077
Practice Address - Fax:575-532-9221
Is Sole Proprietor?:No
Enumeration Date:2005-06-30
Last Update Date:2013-05-23
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CT0433122080N0001X
NMMD2009-05992080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine