Provider Demographics
NPI:1932292364
Name:VADREVU, VIJAYALAKSHMI L D (MD)
Entity Type:Individual
Prefix:
First Name:VIJAYALAKSHMI
Middle Name:L D
Last Name:VADREVU
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:393 E WALNUT ST
Mailing Address - Street 2:3RD FLOOR PHR SYSTEMS
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91188-0001
Mailing Address - Country:US
Mailing Address - Phone:000-000-0000
Mailing Address - Fax:000-000-0000
Practice Address - Street 1:2801 W KINNICKINNIC RIVER PKWY STE 140
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53215-3693
Practice Address - Country:US
Practice Address - Phone:414-385-8725
Practice Address - Fax:414-385-8756
Is Sole Proprietor?:No
Enumeration Date:2006-09-30
Last Update Date:2021-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC52114207W00000X
WI75796-20207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100165427Medicaid
WI75796-20OtherLICENSE