Provider Demographics
NPI:1720003361
Name:DASARI, VIJAYA L (MD, DGO)
Entity Type:Individual
Prefix:
First Name:VIJAYA
Middle Name:L
Last Name:DASARI
Suffix:
Gender:F
Credentials:MD, DGO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 29
Mailing Address - Street 2:
Mailing Address - City:GOSHEN
Mailing Address - State:NY
Mailing Address - Zip Code:10924-0029
Mailing Address - Country:US
Mailing Address - Phone:845-615-1141
Mailing Address - Fax:845-294-4333
Practice Address - Street 1:90 CRYSTAL RUN RD
Practice Address - Street 2:SUITE 403
Practice Address - City:MIDDLETOWN
Practice Address - State:NY
Practice Address - Zip Code:10941-7101
Practice Address - Country:US
Practice Address - Phone:845-703-8806
Practice Address - Fax:845-703-9058
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY210954207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
G83300Medicare UPIN
9X3521Medicare ID - Type Unspecified