Provider Demographics
NPI:1669480224
Name:VIJAYAKUMARAN, PUTHENPARAMPIL G (MD)
Entity Type:Individual
Prefix:
First Name:PUTHENPARAMPIL
Middle Name:G
Last Name:VIJAYAKUMARAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:P
Other - Middle Name:G
Other - Last Name:VIJAYAKUMARAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:6508 KINGS COURT
Mailing Address - Street 2:
Mailing Address - City:WEST BLOOMFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48322-2779
Mailing Address - Country:US
Mailing Address - Phone:734-721-0200
Mailing Address - Fax:734-721-2008
Practice Address - Street 1:33101 ANNAPOLIS
Practice Address - Street 2:SUITE B
Practice Address - City:WAYNE
Practice Address - State:MI
Practice Address - Zip Code:48184-2405
Practice Address - Country:US
Practice Address - Phone:734-721-0200
Practice Address - Fax:734-721-2008
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010406052084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4687157Medicaid
Q26033015Medicare ID - Type Unspecified
MI4687157Medicaid