Provider Demographics
NPI:1780229435
Name:VIJAY KAKUMANU MD LLC
Entity Type:Organization
Organization Name:VIJAY KAKUMANU MD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:VIJAY
Authorized Official - Middle Name:
Authorized Official - Last Name:KAKUMANU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:440-371-4024
Mailing Address - Street 1:4036 CENTER RD UNIT B
Mailing Address - Street 2:
Mailing Address - City:BRUNSWICK
Mailing Address - State:OH
Mailing Address - Zip Code:44212-2945
Mailing Address - Country:US
Mailing Address - Phone:330-225-7733
Mailing Address - Fax:
Practice Address - Street 1:4036 CENTER RD UNIT B
Practice Address - Street 2:
Practice Address - City:BRUNSWICK
Practice Address - State:OH
Practice Address - Zip Code:44212-2945
Practice Address - Country:US
Practice Address - Phone:330-225-7733
Practice Address - Fax:330-220-0902
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-11-16
Last Update Date:2019-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2903960Medicaid