Healthcare Provider Details

I. General information

NPI: 1326669060
Provider Name (Legal Business Name): VIJAY KRISHNA KUPPURAJAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/05/2020
Last Update Date: 11/11/2024
Certification Date: 11/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

707 PALM AVE
IMPERIAL BEACH CA
91932-1229
US

IV. Provider business mailing address

707 PALM AVE
IMPERIAL BEACH CA
91932-1229
US

V. Phone/Fax

Practice location:
  • Phone: 619-429-7700
  • Fax: 619-429-7703
Mailing address:
  • Phone: 619-429-7700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberA183031
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: