Provider Demographics
NPI:1982637906
Name:ACHANTI, VIJAYA (MD)
Entity Type:Individual
Prefix:DR
First Name:VIJAYA
Middle Name:
Last Name:ACHANTI
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 1:20800 WESTGATE MALL
Mailing Address - Street 2:#400
Mailing Address - City:FAIRVIEW PARK
Mailing Address - State:OH
Mailing Address - Zip Code:44126-1323
Mailing Address - Country:US
Mailing Address - Phone:440-356-2272
Mailing Address - Fax:440-356-2299
Practice Address - Street 1:20800 WESTGATE MALL
Practice Address - Street 2:#400
Practice Address - City:FAIRVIEW PARK
Practice Address - State:OH
Practice Address - Zip Code:44126-1323
Practice Address - Country:US
Practice Address - Phone:440-356-2272
Practice Address - Fax:440-356-2299
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35054422174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0736234Medicaid
OHF09555Medicare UPIN