Provider Demographics
NPI:1790886109
Name:TANJORE VENKOBA RAO, VIJOYDEEP (MD)
Entity Type:Individual
Prefix:
First Name:VIJOYDEEP
Middle Name:
Last Name:TANJORE VENKOBA RAO
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 1:434 4TH ST STE 201
Mailing Address - Street 2:
Mailing Address - City:NEWPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37821-3736
Mailing Address - Country:US
Mailing Address - Phone:423-613-1660
Mailing Address - Fax:423-613-1661
Practice Address - Street 1:434 4TH ST STE 201
Practice Address - Street 2:
Practice Address - City:NEWPORT
Practice Address - State:TN
Practice Address - Zip Code:37821-3736
Practice Address - Country:US
Practice Address - Phone:423-613-1660
Practice Address - Fax:423-613-1661
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2020-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA11393R207R00000X
TN48284207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1528818Medicaid