Basic Information
| Provider Information | |||||||||
| NPI: | 1043982606 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | VIKRAMBEHERALLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 84 WATERLINE DR | ||||||||
| Address2: | |||||||||
| City: | ST JOHNS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322592311 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2127679891 | ||||||||
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| Practice Location | |||||||||
| Address1: | 801 OAK ST | ||||||||
| Address2: | |||||||||
| City: | GREEN COVE SPRINGS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 320434317 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9042849230 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/01/2021 | ||||||||
| LastUpdateDate: | 04/04/2022 | ||||||||
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| AuthorizedOfficialLastName: | PAYNE | ||||||||
| AuthorizedOfficialFirstName: | JUDY | ||||||||
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| AuthorizedOfficialTitleorPosition: | ADMIN | ||||||||
| AuthorizedOfficialTelephone: | 9043874778 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 04/04/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.