Basic Information
| Provider Information | |||||||||
| NPI: | 1871512806 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VIJAYVARGIYA | ||||||||
| FirstName: | MANJU | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 8792 | ||||||||
| Address2: | |||||||||
| City: | BELFAST | ||||||||
| State: | ME | ||||||||
| PostalCode: | 049158792 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4402856000 | ||||||||
| FaxNumber: | 2168445922 | ||||||||
| Practice Location | |||||||||
| Address1: | 13207 RAVENNA RD | ||||||||
| Address2: | |||||||||
| City: | CHARDON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 440247032 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4402856000 | ||||||||
| FaxNumber: | 2168445922 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/19/2006 | ||||||||
| LastUpdateDate: | 12/28/2010 | ||||||||
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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 | 2085R0202X | 35-04-8951-V | OH | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 0549179 | 05 | OH | MEDICAID |