Provider Demographics
NPI:1689638587
Name:KUMAR, VIJAY (MD,FCCP)
Entity Type:Individual
Prefix:DR
First Name:VIJAY
Middle Name:
Last Name:KUMAR
Suffix:
Gender:M
Credentials:MD,FCCP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1174 AMAZON WAY
Mailing Address - Street 2:
Mailing Address - City:SIMI VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:93065-3156
Mailing Address - Country:US
Mailing Address - Phone:805-527-5878
Mailing Address - Fax:805-527-0114
Practice Address - Street 1:1174 AMAZON WAY
Practice Address - Street 2:
Practice Address - City:SIMI VALLEY
Practice Address - State:CA
Practice Address - Zip Code:93065-3156
Practice Address - Country:US
Practice Address - Phone:805-527-5878
Practice Address - Fax:805-527-0114
Is Sole Proprietor?:No
Enumeration Date:2006-04-17
Last Update Date:2012-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA46673174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1811024805OtherNPI - CORPORATION TYPE 2
CACMCSUBK0SOtherMCAL SUBMITTER NUMBER
CACMCSUBK0SMedicaid
CA1811024805OtherCORPORATION NPI
CA000022516OtherMEDICARE SUBMITTER NUMBER
CA1689638587OtherNPI - INDIVIDUAL PROFESSIONAL TYPE 1
CAW15531OtherMEDICARE (PTAN) PROVIDER NUMBER
CA00A466730Medicaid
CAA46673OtherSTATE LICENSE
CAGF413ZOtherMEDICARE TYPE 1 PTAN EFFECT 6/27/2012
CAW15531OtherMEDICARE PTAN DEACTIVATED 6/26/2012
CA00A466730OtherBLUE SHIELD
CAGE519AOtherMEDICARE TYPE 2 PTAN EFFECT 6/27/2012
CACMCSUBK0SOtherMCAL SUBMITTER NUMBER