Provider Demographics
NPI:1790935153
Name:TELIVALA, BIJOY PANKAJ (MD)
Entity Type:Individual
Prefix:
First Name:BIJOY
Middle Name:PANKAJ
Last Name:TELIVALA
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 1:7015 AC SKINNER PARKWAY
Mailing Address - Street 2:SUITE 1
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32256
Mailing Address - Country:US
Mailing Address - Phone:904-363-2113
Mailing Address - Fax:904-538-3672
Practice Address - Street 1:5742 BOOTH RD
Practice Address - Street 2:SUITE A
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32207-5982
Practice Address - Country:US
Practice Address - Phone:904-739-7779
Practice Address - Fax:904-739-7771
Is Sole Proprietor?:No
Enumeration Date:2008-09-23
Last Update Date:2016-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD432687207R00000X
PAMT 183359207RH0003X
FLME 106137207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL243756OtherFL-BCBS
FL337784OtherAVMED
FL002294600Medicaid
GA003104112AMedicaid
FL243756OtherFL-BCBS
FL337784OtherAVMED
GA003104112AMedicaid