Provider Demographics
NPI:1720187784
Name:JAYAWARDENA, VINDHYA (MD)
Entity Type:Individual
Prefix:DR
First Name:VINDHYA
Middle Name:
Last Name:JAYAWARDENA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9229 HIGHLAND RD
Mailing Address - Street 2:
Mailing Address - City:WHITE LAKE
Mailing Address - State:MI
Mailing Address - Zip Code:48386-2307
Mailing Address - Country:US
Mailing Address - Phone:248-698-4000
Mailing Address - Fax:248-698-1879
Practice Address - Street 1:9229 HIGHLAND RD
Practice Address - Street 2:
Practice Address - City:WHITE LAKE
Practice Address - State:MI
Practice Address - Zip Code:48386-2307
Practice Address - Country:US
Practice Address - Phone:248-698-4000
Practice Address - Fax:248-698-1879
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301057632207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4250271Medicaid
MIG42153Medicare UPIN
MI0N18900Medicare ID - Type Unspecified