Provider Demographics
NPI:1669695912
Name:VIJAYKUMAR, SUDHA (MD)
Entity type:Individual
Prefix:
First Name:SUDHA
Middle Name:
Last Name:VIJAYKUMAR
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 1:9320A ROOSEVELT AVE
Mailing Address - Street 2:2ND FL
Mailing Address - City:JACKSON HEIGHTS
Mailing Address - State:NY
Mailing Address - Zip Code:11372
Mailing Address - Country:US
Mailing Address - Phone:718-334-6793
Mailing Address - Fax:718-334-6717
Practice Address - Street 1:9320A ROOSEVELT AVE
Practice Address - Street 2:2ND FL
Practice Address - City:JACKSON HTS
Practice Address - State:NY
Practice Address - Zip Code:11372
Practice Address - Country:US
Practice Address - Phone:718-334-6700
Practice Address - Fax:718-334-6701
Is Sole Proprietor?:No
Enumeration Date:2007-04-11
Last Update Date:2012-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY217986208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02133099Medicaid
H31827Medicare UPIN