Healthcare Provider Details

I. General information

NPI: 1285374876
Provider Name (Legal Business Name): VIJAY KODUMUDI MD, MBA, MPH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/31/2022
Last Update Date: 03/26/2026
Certification Date: 03/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4733 W SUNSET BLVD FL 3
LOS ANGELES CA
90027-6093
US

IV. Provider business mailing address

4733 W SUNSET BLVD FL 3
LOS ANGELES CA
90027-6093
US

V. Phone/Fax

Practice location:
  • Phone: 833-574-2273
  • Fax:
Mailing address:
  • Phone: 833-574-2273
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number3013516
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: