Basic Information
| Provider Information | |||||||||
| NPI: | 1669762795 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DAMARLA | ||||||||
| FirstName: | VIJAY | ||||||||
| MiddleName: | KUMAR | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | DAMARLA | ||||||||
| OtherFirstName: | VENKATA DARMA VEERA | ||||||||
| OtherMiddleName: | VIJAY KUMAR | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 8940 N WOOD SAGE RD | ||||||||
| Address2: | |||||||||
| City: | PEORIA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 616157822 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3092433610 | ||||||||
| FaxNumber: | 3092433274 | ||||||||
| Practice Location | |||||||||
| Address1: | 8940 N WOOD SAGE RD | ||||||||
| Address2: | |||||||||
| City: | PEORIA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 616157822 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3092433000 | ||||||||
| FaxNumber: | 3092433274 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/11/2011 | ||||||||
| LastUpdateDate: | 10/13/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/13/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RH0003X | 036146175 | IL | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology |
No ID Information.