Provider Demographics
NPI:1245299502
Name:SHASTRI, VIJAYA (MD)
Entity type:Individual
Prefix:
First Name:VIJAYA
Middle Name:
Last Name:SHASTRI
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 1:3950 HOLLYWOOD RD
Mailing Address - Street 2:SUITE 270
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MI
Mailing Address - Zip Code:49085-9159
Mailing Address - Country:US
Mailing Address - Phone:269-983-3386
Mailing Address - Fax:269-983-7943
Practice Address - Street 1:3950 HOLLYWOOD RD
Practice Address - Street 2:SUITE 270
Practice Address - City:SAINT JOSEPH
Practice Address - State:MI
Practice Address - Zip Code:49085-9159
Practice Address - Country:US
Practice Address - Phone:269-983-3386
Practice Address - Fax:269-983-7943
Is Sole Proprietor?:No
Enumeration Date:2006-03-23
Last Update Date:2016-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIVS040679207RA0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RA0000XAllopathic & Osteopathic PhysiciansInternal MedicineAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI370016279OtherRAIL ROAD MEDICARE
MI0A110280OtherBCBS
MIB47926Medicare UPIN
MI0M94300Medicare PIN
MI0A110280OtherBCBS