Basic Information
| Provider Information | |||||||||
| NPI: | 1669480224 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VIJAYAKUMARAN | ||||||||
| FirstName: | PUTHENPARAMPIL | ||||||||
| MiddleName: | G | ||||||||
| NamePrefix: | |||||||||
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| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | VIJAYAKUMARAN | ||||||||
| OtherFirstName: | P | ||||||||
| OtherMiddleName: | G | ||||||||
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| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 6508 KINGS COURT | ||||||||
| Address2: | |||||||||
| City: | WEST BLOOMFIELD | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483222779 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7347210200 | ||||||||
| FaxNumber: | 7347212008 | ||||||||
| Practice Location | |||||||||
| Address1: | 33101 ANNAPOLIS | ||||||||
| Address2: | SUITE B | ||||||||
| City: | WAYNE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481842405 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7347210200 | ||||||||
| FaxNumber: | 7347212008 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/03/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | 4301040605 | MI | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 4687157 | 05 | MI | MEDICAID |