Provider Demographics
NPI:1720089345
Name:VINJAMURI, VINOD K (MD)
Entity Type:Individual
Prefix:
First Name:VINOD
Middle Name:K
Last Name:VINJAMURI
Suffix:
Gender:M
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:PO BOX 279
Mailing Address - Street 2:
Mailing Address - City:GLENEDEN BEACH
Mailing Address - State:OR
Mailing Address - Zip Code:97388-0279
Mailing Address - Country:US
Mailing Address - Phone:541-764-3360
Mailing Address - Fax:541-764-3362
Practice Address - Street 1:6615 GLENEDEN BEACH LOOP
Practice Address - Street 2:
Practice Address - City:GLENEDEN BEACH
Practice Address - State:OR
Practice Address - Zip Code:97388-9700
Practice Address - Country:US
Practice Address - Phone:541-764-3360
Practice Address - Fax:541-764-3362
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD18179207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR051867Medicaid
115453Medicare ID - Type Unspecified
OR051867Medicaid