Provider Demographics
NPI:1922281641
Name:DANIEL VIJJESWARAPU M.D. P.A.
Entity Type:Organization
Organization Name:DANIEL VIJJESWARAPU M.D. P.A.
Other - Org Name:KIDS DOC CC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:VIJJESWARAPU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:361-814-8453
Mailing Address - Street 1:3240 FORT WORTH ST
Mailing Address - Street 2:SUITE 111
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78411-2459
Mailing Address - Country:US
Mailing Address - Phone:361-814-8453
Mailing Address - Fax:361-814-0487
Practice Address - Street 1:3240 FORT WORTH ST
Practice Address - Street 2:SUITE 111
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78411-2459
Practice Address - Country:US
Practice Address - Phone:361-814-8453
Practice Address - Fax:361-814-0487
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-17
Last Update Date:2009-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK7115208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX127087807Medicaid
TX159629801Medicaid
TX159629803Medicaid
TX127087807Medicaid