Provider Demographics
NPI:1790882850
Name:LINGAM, VIJAY R (MD)
Entity Type:Individual
Prefix:
First Name:VIJAY
Middle Name:R
Last Name:LINGAM
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:PO BOX 3084
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70602-3084
Mailing Address - Country:US
Mailing Address - Phone:337-436-7560
Mailing Address - Fax:337-433-9861
Practice Address - Street 1:2555 JIMMY JOHNSON BLVD
Practice Address - Street 2:
Practice Address - City:PORT ARTHUR
Practice Address - State:TX
Practice Address - Zip Code:77640-2007
Practice Address - Country:US
Practice Address - Phone:409-724-7389
Practice Address - Fax:409-853-5110
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2008-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK6103207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX118186903Medicaid
TX8639K0Medicare PIN
050075757Medicare PIN
TX118186903Medicaid