Basic Information
| Provider Information | |||||||||
| NPI: | 1174018642 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LEELARUBAN | ||||||||
| FirstName: | VISHNUVENI | ||||||||
| MiddleName: | |||||||||
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| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | KANDASAMY | ||||||||
| OtherFirstName: | VISHNUVENI | ||||||||
| OtherMiddleName: | |||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 355 BARD AVE DEPT OF | ||||||||
| Address2: | |||||||||
| City: | STATEN ISLAND | ||||||||
| State: | NY | ||||||||
| PostalCode: | 103101664 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7188182419 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 725 S QUEEN ST | ||||||||
| Address2: | |||||||||
| City: | DOVER | ||||||||
| State: | DE | ||||||||
| PostalCode: | 199043568 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3026784488 | ||||||||
| FaxNumber: | 3026784497 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/27/2018 | ||||||||
| LastUpdateDate: | 08/04/2021 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/04/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | C1-0024260 | DE | Y | Allopathic & Osteopathic Physicians | Internal Medicine | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.