Provider Demographics
NPI:1821024100
Name:GANDLA, VIJAYA BHASKAR (MD)
Entity Type:Individual
Prefix:DR
First Name:VIJAYA
Middle Name:BHASKAR
Last Name:GANDLA
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:MEDICAL CENTER BLVD
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27157-0001
Mailing Address - Country:US
Mailing Address - Phone:336-713-5215
Mailing Address - Fax:336-716-0030
Practice Address - Street 1:601 N ELM ST
Practice Address - Street 2:
Practice Address - City:HIGH POINT
Practice Address - State:NC
Practice Address - Zip Code:27262-4331
Practice Address - Country:US
Practice Address - Phone:336-878-6419
Practice Address - Fax:336-878-6420
Is Sole Proprietor?:No
Enumeration Date:2006-06-25
Last Update Date:2021-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2008-00921207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC149YGOtherBCBS OF NC
NC5910711Medicaid
NC149YGOtherBCBS OF NC
NC5910711Medicaid