Provider Demographics
NPI:1891996880
Name:MIRYALA, VINOD R (MD)
Entity Type:Individual
Prefix:
First Name:VINOD
Middle Name:R
Last Name:MIRYALA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:308 W HIGHLAND BLVD
Mailing Address - Street 2:
Mailing Address - City:INVERNESS
Mailing Address - State:FL
Mailing Address - Zip Code:34452-4716
Mailing Address - Country:US
Mailing Address - Phone:352-726-8353
Mailing Address - Fax:352-726-5038
Practice Address - Street 1:910 OLD CAMP RD
Practice Address - Street 2:BLDG 210
Practice Address - City:THE VILLAGES
Practice Address - State:FL
Practice Address - Zip Code:32162-5604
Practice Address - Country:US
Practice Address - Phone:352-751-3356
Practice Address - Fax:352-751-3359
Is Sole Proprietor?:No
Enumeration Date:2007-05-29
Last Update Date:2023-10-11
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
FLME75516207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL43462OtherBCBS OF FL
FL77940OtherBCBS OF FL GROUP ID
FLME75516OtherSTATE MEDICAL LICENSE
FL269859500OtherMEDICAID GROUP
FLCF1416OtherMEDICARE RR GROUP
FLP00455415OtherMEDICARE RR
FL254028200Medicaid
FL10715924OtherCAQH
FL7390633OtherCIGNA
FL77940OtherMEDICARE GROUP ID
FL10715924OtherCAQH
FLG72190Medicare UPIN