Healthcare Provider Details

I. General information

NPI: 1033208160
Provider Name (Legal Business Name): MALAYATTIL VIJAYALAKSHMI M.D
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/12/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3325 PALO VERDE AVE SUITE 203
LONG BEACH CA
90808-4132
US

IV. Provider business mailing address

3993 FARQUHAR AVE
LOS ALAMITOS CA
90720-2018
US

V. Phone/Fax

Practice location:
  • Phone: 562-421-8283
  • Fax: 562-420-8681
Mailing address:
  • Phone: 562-421-8283
  • Fax: 562-420-8681

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License NumberA80745
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: