Provider Demographics
NPI:1669470555
Name:PETHKAR, VIJAY (MD)
Entity Type:Individual
Prefix:
First Name:VIJAY
Middle Name:
Last Name:PETHKAR
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 1:780 NORTH MT JULIET RD
Mailing Address - Street 2:
Mailing Address - City:MT JULIET
Mailing Address - State:TN
Mailing Address - Zip Code:37122-0780
Mailing Address - Country:US
Mailing Address - Phone:615-727-1963
Mailing Address - Fax:615-758-4821
Practice Address - Street 1:780 NORTH MT JULIET RD
Practice Address - Street 2:
Practice Address - City:MT JULIET
Practice Address - State:TN
Practice Address - Zip Code:37122-0780
Practice Address - Country:US
Practice Address - Phone:615-758-9273
Practice Address - Fax:615-758-4821
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-13
Last Update Date:2023-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD31687174400000X
TN031687207RS0012X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No174400000XOther Service ProvidersSpecialist
No207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4102896OtherBLUE CROSS BLUE SHIELD TN
G34839Medicare UPIN
TNG34839Medicare UPIN