Provider Demographics
NPI:1215992615
Name:VIBOOSHANAN, PANDIAN PAUL (MD)
Entity type:Individual
Prefix:DR
First Name:PANDIAN
Middle Name:PAUL
Last Name:VIBOOSHANAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:385 SOUTH CATALINA AVE, APT 1125
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91106
Mailing Address - Country:US
Mailing Address - Phone:315-378-9578
Mailing Address - Fax:315-464-2010
Practice Address - Street 1:8316 FOOD HILLS BLVD
Practice Address - Street 2:
Practice Address - City:SUNLAND
Practice Address - State:CA
Practice Address - Zip Code:91040
Practice Address - Country:US
Practice Address - Phone:818-273-8925
Practice Address - Fax:818-844-5090
Is Sole Proprietor?:No
Enumeration Date:2006-04-19
Last Update Date:2019-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY186395208000000X
CAC147787208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYF63026Medicare UPIN
NYRA9729Medicare ID - Type Unspecified