Provider Demographics
NPI:1245330935
Name:VIJAYAKUMAR, VANI (MD)
Entity type:Individual
Prefix:
First Name:VANI
Middle Name:
Last Name:VIJAYAKUMAR
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:VANIKUMARI
Other - Middle Name:
Other - Last Name:ANANTHABOTLA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:2500 N STATE ST
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4500
Mailing Address - Country:US
Mailing Address - Phone:601-815-5615
Mailing Address - Fax:
Practice Address - Street 1:1514 JEFFERSON HWY
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70121-2483
Practice Address - Country:US
Practice Address - Phone:504-842-3470
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-23
Last Update Date:2024-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC52110207U00000X
IL36071489207U00000X
TXL5169207U00000X
MS19800207U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207U00000XAllopathic & Osteopathic PhysiciansNuclear Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSP00436436OtherRAILROAD MEDICARE
MSP01620197OtherRAILROAD MEDICARE PTAN
MS00050780Medicaid
TX149847901Medicaid
TX360004405Medicare ID - Type Unspecified
MS512I300038Medicare PIN
MSP00436436OtherRAILROAD MEDICARE
MS00050780Medicaid
MS302I305439Medicare PIN