Basic Information
Provider Information | |||||||||
NPI: | 1154741932 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | NAIR | ||||||||
FirstName: | VIJAYALEKSHMI | ||||||||
MiddleName: | VARADA | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 571 SAINT JOSEPHS BLVD FL 2 | ||||||||
Address2: |   | ||||||||
City: | ELMIRA | ||||||||
State: | NY | ||||||||
PostalCode: | 149013230 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6072712050 | ||||||||
FaxNumber: | 6078731244 | ||||||||
Practice Location | |||||||||
Address1: | 123 CONHOCTON ST STE 103 | ||||||||
Address2: |   | ||||||||
City: | CORNING | ||||||||
State: | NY | ||||||||
PostalCode: | 148302959 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6074381200 | ||||||||
FaxNumber: | 6074381221 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/21/2014 | ||||||||
LastUpdateDate: | 11/25/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 11/25/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P2900X | 294627 | NY | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Pain Medicine | 2084S0012X | 294627 | NY | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Sleep Medicine |
ID Information
ID | Type | State | Issuer | Description | 103803129 | 05 | PA |   | MEDICAID | 06075387 | 05 | NY |   | MEDICAID |