Provider Demographics
NPI:1255715397
Name:VIJAY SHANMUGAM M D INC
Entity type:Organization
Organization Name:VIJAY SHANMUGAM M D INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MALAVIKA
Authorized Official - Middle Name:
Authorized Official - Last Name:VIJAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:661-726-9220
Mailing Address - Street 1:44215 N 15TH ST WEST
Mailing Address - Street 2:STE 204
Mailing Address - City:LANCASTER
Mailing Address - State:CA
Mailing Address - Zip Code:93534-5504
Mailing Address - Country:US
Mailing Address - Phone:661-726-9220
Mailing Address - Fax:661-726-0240
Practice Address - Street 1:44215 N 15TH ST WEST
Practice Address - Street 2:STE 204
Practice Address - City:LANCASTER
Practice Address - State:CA
Practice Address - Zip Code:93534-5504
Practice Address - Country:US
Practice Address - Phone:661-726-9220
Practice Address - Fax:661-726-0240
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-18
Last Update Date:2015-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA667872084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A667870Medicaid
CAG80772Medicare UPIN
CA00A667870Medicaid