MEDICARE: VIJAYAKUMAR PRAVEEN MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2080N0001X	Neonatal-Perinatal Medicine Physician	043312	CT
2	2080N0001X	Neonatal-Perinatal Medicine Physician	MD2009-0599	NM

General Provider Information

NPI Number	:	1659378008
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	VIJAYAKUMAR PRAVEEN MD

Provider Business Mailing Address
First Line	:	4351 E LOHMAN AVE
Second Line	:	SUITE 100
City	:	LAS CRUCES
State	:	NM
Zip	:	88011-8259
Country	:	US
Telephone Number	:	575-532-9077
Fax Number	:	575-532-9221

Provider Business Practice Location Address
First Line	:	4351 E LOHMAN AVE
Second Line	:	SUITE 100
City	:	LAS CRUCES
State	:	NM
Zip	:	88011-8259
Country	:	US
Telephone Number	:	575-532-9077
Fax Number	:	575-532-9221

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/30/2005
Last Update Date	:	05/23/2013

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