Provider Demographics
NPI:1982792818
Name:VISWANATHAN, VIJAY (MD)
Entity Type:Individual
Prefix:DR
First Name:VIJAY
Middle Name:
Last Name:VISWANATHAN
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 1:640 S. STATE ST
Mailing Address - Street 2:MAIL CODE 3055
Mailing Address - City:DOVER
Mailing Address - State:DE
Mailing Address - Zip Code:19901-3530
Mailing Address - Country:US
Mailing Address - Phone:302-480-1688
Mailing Address - Fax:302-480-9807
Practice Address - Street 1:640 S STATE ST
Practice Address - Street 2:
Practice Address - City:DOVER
Practice Address - State:DE
Practice Address - Zip Code:19901-3530
Practice Address - Country:US
Practice Address - Phone:302-480-1688
Practice Address - Fax:302-480-9807
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2023-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC1-00093942085N0700X, 2085N0904X, 2085R0202X
MDD00688872085R0202X
MA2303052085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiology
No2085N0904XAllopathic & Osteopathic PhysiciansRadiologyNuclear Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00751354OtherAAD RR PTAN
MDS645OtherAAD BCBS
MD417828900Medicaid
MD1073OtherAAD BLUE CHOICE
MD156383ZDYCOtherRR MEDICARE ARA PTAN
MD1073OtherAAD BCBS REGIONAL PLANS
MD3811OtherAAD SHIPLEYS BLUE CHOICE
MDKC46SHOtherAAD SHIPLEYS BCBS
MDS629Medicare PIN