Provider Demographics
NPI:1710953666
Name:RAHULAN, VIJIL K (MD)
Entity Type:Individual
Prefix:
First Name:VIJIL
Middle Name:K
Last Name:RAHULAN
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 1:2885 SANFORD AVE SW
Mailing Address - Street 2:SUITE NO. 18083
Mailing Address - City:GRANDVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:49418-1342
Mailing Address - Country:US
Mailing Address - Phone:810-982-7243
Mailing Address - Fax:
Practice Address - Street 1:2885 SANFORD AVE SW
Practice Address - Street 2:SUITE NO. 18083
Practice Address - City:GRANDVILLE
Practice Address - State:MI
Practice Address - Zip Code:49418-1342
Practice Address - Country:US
Practice Address - Phone:810-982-7243
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-28
Last Update Date:2017-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301078860207RC0200X, 207RP1001X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4485080Medicaid
H80016Medicare UPIN