Basic Information
| Provider Information | |||||||||
| NPI: | 1982792818 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VISWANATHAN | ||||||||
| FirstName: | VIJAY | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 2002 MEDICAL PKWY STE 235 | ||||||||
| Address2: | |||||||||
| City: | ANNAPOLIS | ||||||||
| State: | MD | ||||||||
| PostalCode: | 214013260 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4102662770 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2002 MEDICAL PKWY STE 235 | ||||||||
| Address2: | |||||||||
| City: | ANNAPOLIS | ||||||||
| State: | MD | ||||||||
| PostalCode: | 214013260 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4102662770 | ||||||||
| FaxNumber: | 4108416251 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/10/2006 | ||||||||
| LastUpdateDate: | 12/16/2010 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 230305 | MA | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | D0068887 | MD | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 417828900 | 05 | MD | MEDICAID | 1073 | 01 | MD | AAD BLUE CHOICE | OTHER | 156383ZDYC | 01 | MD | RR MEDICARE ARA PTAN | OTHER | S645 | 01 | MD | AAD BCBS | OTHER | P00751354 | 01 | AAD RR PTAN | OTHER | 1073 | 01 | MD | AAD BCBS REGIONAL PLANS | OTHER | 3811 | 01 | MD | AAD SHIPLEYS BLUE CHOICE | OTHER | KC46SH | 01 | MD | AAD SHIPLEYS BCBS | OTHER |