Basic Information
| Provider Information | |||||||||
| NPI: | 1699799833 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RAO | ||||||||
| FirstName: | VIJENDRA | ||||||||
| MiddleName: | |||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1516 COTNER AVE | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900253303 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3104452951 | ||||||||
| FaxNumber: | 3104791459 | ||||||||
| Practice Location | |||||||||
| Address1: | 1516 COTNER AVE | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900253303 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3104452951 | ||||||||
| FaxNumber: | 3104791459 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/27/2006 | ||||||||
| LastUpdateDate: | 12/20/2021 | ||||||||
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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 | 2085R0202X | A91225 | CA | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | GR0106039 | 05 | CA | MEDICAID | GR0106035 | 05 | CA | MEDICAID | GR010603D | 05 | CA | MEDICAID | 00A912250 | 05 | CA | MEDICAID | GR0025330 | 05 | CA | MEDICAID |