Provider Demographics
NPI:1811024805
Name:VIJAY KUMAR MD A MEDICAL CORPORATION
Entity Type:Organization
Organization Name:VIJAY KUMAR MD A MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:VIJAY
Authorized Official - Middle Name:
Authorized Official - Last Name:KUMAR
Authorized Official - Suffix:
Authorized Official - Credentials:MD,FCCP
Authorized Official - Phone:805-527-5878
Mailing Address - Street 1:1174 AMAZON WAY
Mailing Address - Street 2:
Mailing Address - City:SIMI VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:93065-3156
Mailing Address - Country:US
Mailing Address - Phone:805-527-5878
Mailing Address - Fax:805-527-0114
Practice Address - Street 1:1174 AMAZON WAY
Practice Address - Street 2:
Practice Address - City:SIMI VALLEY
Practice Address - State:CA
Practice Address - Zip Code:93065-3156
Practice Address - Country:US
Practice Address - Phone:805-527-5878
Practice Address - Fax:805-527-0114
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-27
Last Update Date:2020-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA46673174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACMCSUBK0SOtherMEDICAID SUBMITTER NUMBER
CA1811024805OtherNPI - CORPORATION TYPE 2
CA00A466730Medicaid
CA00A466730OtherBLUE SHIELD
CAGE519AOtherMEDICARE TYPE 2 PTAN EFFECT 6/27/2012
CAGF413ZOtherMEDICARE TYPE 1 PTAN EFFECT 6/27/2012
CAW15531OtherMEDICARE (PTAN) PROVIDER NUMBER
CA1689638587OtherNPI - INDIVIDUAL PROFESSIONAL TYPE 1
CA1689638587OtherNPI INDIVIDUAL NUMBER
CAW15531OtherMEDICARE PTAN DEACTIVATED 6/26/2012
CAA46673OtherLICENSE
CAW15531OtherMEDICARE PTAN DEACTIVATED 6/26/2012
CA1689638587OtherNPI INDIVIDUAL NUMBER