Basic Information
| Provider Information | |||||||||
| NPI: | 1467441790 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NAGABHAIRU | ||||||||
| FirstName: | VIJAYA | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 39 E ATWATER AVE | ||||||||
| Address2: | SUITE A | ||||||||
| City: | EUSTIS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 327265540 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3524830900 | ||||||||
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| Practice Location | |||||||||
| Address1: | 212 S FLORIDA ST | ||||||||
| Address2: | |||||||||
| City: | BUSHNELL | ||||||||
| State: | FL | ||||||||
| PostalCode: | 335136703 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3527932441 | ||||||||
| FaxNumber: | 3527933282 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/19/2005 | ||||||||
| LastUpdateDate: | 03/20/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | ME89894 | FL | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 274016800 | 05 | FL | MEDICAID |